A nurse is caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take?

Provide chilled formula.

Administer feedings at a slower rate.

Discard the open can of formula after 36 hr.

Flush the tube with 10 mL of water after feedings.

Answer and Explanation

The Correct Answer is B

A. Provide chilled formula: Chilled formula can be less palatable and may cause gastrointestinal discomfort, potentially worsening diarrhea. Room temperature or slightly warmed formula is generally recommended for enteral feedings to enhance tolerance and digestion.

B. Administer feedings at a slower rate: Slowing the rate of enteral feedings can help reduce gastrointestinal irritation and improve absorption, which may be particularly beneficial for a client experiencing diarrhea. This approach allows the intestines more time to process the nutrients, potentially alleviating symptoms.

C. Discard the open can of formula after 36 hr: While proper storage is important, many enteral formulas can be stored for up to 48 hours once opened. The key is to ensure the formula is stored correctly to prevent bacterial growth, but the 36-hour guideline may not be strictly necessary in all cases.

D. Flush the tube with 10 mL of water after feedings: Flushing the tube is a good practice to maintain tube patency, but the volume may not be adequate depending on the tube size and the specific protocol. Adequate flushing is essential, but it does not directly address the issue of diarrhea, which is the priority concern in this scenario.

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Correct Answer is D

Explanation

A. Bradypnea: This refers to a slower than normal respiratory rate, which is not a typical manifestation of pulmonary congestion. In fact, pulmonary congestion often leads to tachypnea (increased respiratory rate).

B. Jugular vein distention: This is more indicative of right-sided heart failure or fluid overload rather than left-sided heart failure, where the primary issue is related to pulmonary congestion.

C. Weight gain: While weight gain can occur due to fluid retention in heart failure, it is not specific to pulmonary congestion and can be seen in both left-sided and right-sided heart failure.

D. Frothy, pink sputum: This is a classic manifestation of pulmonary congestion and indicates the presence of fluid in the lungs, often seen in left-sided heart failure. The pink color is due to the presence of blood, which may leak into the alveoli due to increased pressure. This finding is critical and should be closely monitored.

A. Edema B. Weight loss C. Muscle weakness D. Fever

Correct Answer is C

Explanation

A) Edema: While edema can occur in some patients, it is not a common or serious side effect of simvastatin. Clients should monitor for any unusual swelling, but it is not the primary concern associated with this medication.

B) Weight loss: Weight loss is not typically associated with simvastatin use. Clients should be aware of their weight but reporting weight loss alone is not usually necessary unless it is significant or accompanied by other concerning symptoms.

C) Muscle weakness: Simvastatin can lead to muscle-related side effects, including myopathy and rhabdomyolysis, which can present as muscle weakness. It is critical for clients to monitor for any unexplained muscle pain, tenderness, or weakness and report these symptoms to the provider, as early intervention can prevent serious complications.

D) Fever: Fever is not a typical side effect of simvastatin. While clients should report any signs of infection or unusual symptoms, fever alone is not specifically linked to the use of this medication and does not warrant immediate concern related to simvastatin therapy.

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A nurse is caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of pulmonary congestion?

Correct Answer is D

Explanation

A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?

Correct Answer is C

Explanation

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