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 C
Explanation
Choice A rationale
Monitoring and documenting findings without intervention ignores the critical need to manage intracranial pressure (ICP). Normal ICP is 7-15 mmHg, and 25 mmHg indicates a dangerous elevation requiring prompt corrective actions.
Choice B rationale
Suctioning can trigger a vagal response, further increasing ICP. Interventions should aim to decrease ICP, not exacerbate it. Careful suctioning is used when airway clearance is critical, not as a routine measure.
Choice C rationale
Raising the head of the bed to 35–45 degrees promotes venous drainage, reducing ICP. Alerting the physician ensures timely medical interventions. This is the primary recommended action for elevated ICP cases.
Choice D rationale
Lowering the head of the bed can worsen ICP by impairing venous outflow. Padded side rails are useful for seizure precautions but are irrelevant for managing elevated ICP in this situation.
Correct Answer is B
Explanation
Choice A rationale
Basilar skull fractures can lead to cerebral injuries and CSF leaks, but do not typically cause anoxic brain injury unless they compromise oxygenation or cause cerebral edema severely reducing blood flow.
Choice B rationale
Prolonged submersion compromises oxygen delivery, leading to diffuse cerebral hypoxia or anoxia, the primary cause of brain injury in drowning victims due to interruption of arterial oxygenation over unknown durations.
Choice C rationale
Epidural or subdural hematomas elevate intracranial pressure and compress brain tissue, but they are not as immediately hypoxic as situations involving complete oxygen deprivation like submersion.
Choice D rationale
Prolonged seizures, or status epilepticus, may disrupt normal metabolic processes, potentially causing neuronal injury. However, primary hypoxia is generally less pronounced than in submersion cases.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.