A nurse is caring for a client who has a small-bore jejunostomy tube and is receiving a continuous tube feeding with a high-viscosity formula. Which of the following actions should the nurse take to prevent the tubing from clogging?
Replace the bag and tubing every 24 hr.
Flush the tubing with 10 mL water every 6 hr.
Administer the feeding by gravity drip.
Heat the formula prior to infusion.
The Correct Answer is B
A) While it's important to change the feeding bag and tubing regularly to pr’vent bacterial growth and contamination, replacing them every 24 hours may not be necessary unless otherwise indicated by facility policy or if there are signs of contamination or malfunction. Routine replacement every 24 hours is not specifically indicated for preventing tubing clogging.
B) Flushing the tubing with water every 6 hours is an effective method to prevent clogging, especially when using a high-viscosity formula. Flushing helps ensure that the formula does not solidify or adhere to the inner walls of the tubing, maintaining its patency and preventing obstruction.
C) Administering the feeding by gravity drip is a method of delivery rather than a preventive measure against tubing clogging. While gravity drip administration may be appropriate for certain types of tube feedings, it does not directly address the prevention of tubing clogging.
D) Heating the formula prior to infusion may help improve its flow characteristics, especially if the formula has thickened due to being refrigerated. However, this action alone may not be sufficient to prevent tubing clogging. Flushing the tubing with water at regular intervals is a more direct and effective preventive measure in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Place an identification bracelet:
While important for identification purposes, placing an identification bracelet is not the priority immediately following birth. Ensuring the newborn's physiological stability takes precedence.
B. Administer eye prophylaxis:
Administering eye prophylaxis is an essential newborn care procedure to prevent neonatal conjunctivitis caused by exposure to maternal gonorrhea or chlamydia. However, it is not the priority immediately after ensuring a patent airway.
C. Administer vitamin K:
Administering vitamin K is important for preventing vitamin K deficiency bleeding (VKDB) in newborns. However, it is typically done after drying the skin and other immediate newborn care tasks.
D. Dry the skin:
This is the correct answer. Drying the newborn's skin is the priority after ensuring a patent airway. Drying helps prevent heat loss and stimulates the newborn's breathing and circulation. It is an essential step in newborn care immediately after birth to promote thermal stability and adaptation to extrauterine life.
Correct Answer is A
Explanation
A) Identify the client's motivation: Understanding the client's motivation for wanting to lose weight is crucial as it helps the nurse tailor interventions and support strategies to align with the client's goals and values. By identifying the client's motivation, the nurse can determine what drives the client's desire to lose weight, whether it's improving health, enhancing self-esteem, or addressing specific concerns. This information forms the foundation for developing an effective and individualized care plan.
B) Refer the client to a dietitian: While a referral to a dietitian is an important step in the weight loss process, it may not be the first action the nurse takes. Before making a referral, it's essential to assess the client's motivation, readiness to change, and current understanding of weight loss strategies. This information helps ensure that the dietitian can provide targeted guidance and support based on the client's specific needs and preferences.
C) Set a weight loss goal: Setting a weight loss goal is an important aspect of the weight loss journey; however, it typically occurs after assessing the client's motivation and readiness to change. Setting realistic and achievable goals collaboratively with the client allows for better engagement and commitment to the weight loss plan. Without understanding the client's motivation and readiness, setting a goal may not be meaningful or sustainable.
D) Discuss behavior modification: Behavior modification strategies play a crucial role in achieving and maintaining weight loss success. However, before discussing specific behavior modification techniques, it's essential to assess the client's motivation, barriers to change, and current behaviors. Understanding these factors helps tailor behavior modification strategies to address the client's unique needs and challenges effectively.
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