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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Crossing the lower extremities and turning the hips and shoulders separately risks twisting or misalignment of the spinal column, which is contraindicated in spinal cord injury patients.
Choice B rationale
Asking the patient to assist by grasping the side rail is inappropriate as it may worsen the injury or result in unsafe movement, especially if the spinal cord is unstable.
Choice C rationale
Moving the patient independently with a draw sheet is unsafe due to the risk of misalignment or additional spinal damage, necessitating assistance and a coordinated approach.
Choice D rationale
Log rolling with one person holding the head and two others moving the body ensures spinal alignment and minimizes further injury during repositioning of spinal cord injury patients.
Correct Answer is B
Explanation
Choice A rationale
Non-tender lymph nodes and productive cough are more suggestive of later-stage infections or malignancies, not early HIV presentation which resembles acute viral syndrome.
Choice B rationale
Flu-like symptoms such as chills and aches occur during acute retroviral syndrome due to initial viral replication and immune response shortly after HIV infection.
Choice C rationale
Abdominal cramping and loose stools are associated with gastrointestinal infections in later stages of HIV due to opportunistic pathogens, not acute early-stage presentation.
Choice D rationale
High fever, severe headache, and change in mentation are indicative of central nervous system infections or complications in advanced HIV stages, not early acute HIV symptoms.
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