A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.
For safe administration, the nurse should:

Hold the feeding if the client has soft brown stools and is passing flatus.

Dilute each medication with 5% dextrose in water (D5W) and flush with at least 30 mL.

Discuss the order with the prescriber if the client's abdomen is distended with hypoactive bowel sounds and RLQ tenderness.

Check for residual enteral formula prior to administration.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.

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Correct Answer is ["56"]

Explanation

Step 1 is (250 mL ÷ 90 min) × 20 gtt/mL.

Step 2 is (2.777 mL/min × 20 gtt/mL).

Step 3 is 55.55 gtts/min. The final calculated answer is 56 gtts/min.

Correct Answer is ["2525"]

Explanation

Step 1 is calculate intake from lactated Ringer’s: 150 mL/hr × 9 hrs = 1350 mL.

Step 2 is calculate cefazolin intake: 100 mL × 1 dose = 100 mL.

Step 3 is calculate intake from two units of packed RBCs: 275 mL + 250 mL = 525 mL.

Step 4 is calculate intake from two IV boluses: 250 mL × 2 = 500 mL.

Step 5 is calculate intake from ranitidine infusion: 50 mL × 1 dose = 50 mL.

Step 6 is calculate total intake: 1350 mL + 100 mL + 525 mL + 500 mL + 50 mL = 2525 mL. Final calculated intake is 2525 mL.

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A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.For safe administration, the nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is to receive 250 mL of IV fluid over 90 minutes by gravity. The drop factor on the IV tubing is 20 gtts/mL. How many gtts/min should be administered?

Correct Answer is ["56"]

Explanation

Correct Answer is ["2525"]

Explanation

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A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.
For safe administration, the nurse should: