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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
No explanation
Correct Answer is B
Explanation
A) Vomiting: While nausea and vomiting can occur during pregnancy, they are not specific complications related to amniocentesis. The nurse should focus on more serious potential complications following the procedure.
B) Contractions: This is the most relevant complication to monitor for after an amniocentesis. The procedure can stimulate uterine contractions, which may lead to preterm labor, especially at 33 weeks of gestation. Monitoring for contractions is essential to ensure the safety of both the mother and the fetus.
C) Hypertension: Hypertension is not a direct complication associated with amniocentesis. While the stress of the procedure may affect blood pressure, it is not a typical monitoring concern immediately following the procedure.
D) Epigastric pain: Although epigastric pain can occur in pregnancy, it is not a specific complication of amniocentesis. Monitoring should focus on uterine activity and signs of labor rather than general abdominal pain unless it is severe or accompanied by other concerning symptoms.
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