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?
Flush the tube with 10 mL of water after feedings.
Discard the open can of formula after 36 hr.
Administer feedings at a slower rate.
Provide chilled formula.
The Correct Answer is C
A. Flushing the tube with water after feedings helps to prevent tube clogging and ensures adequate delivery of enteral feedings. However, it does not address the diarrhea.
B. While it's important to discard open cans of formula within a specified timeframe to prevent bacterial growth, diarrhea in the client is not directly addressed by discarding formula after 36 hours.
C. The nurse should consider administering feedings at a slower rate to manage diarrhea. This approach can help reduce the incidence of diarrhea as it allows for better absorption of the nutrients.
D. Providing chilled formula is not typically indicated for clients with diarrhea and may not be well-tolerated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Tachycardia might occur due to the fever itself but isn't a specific reaction to the cooling method.
B: Shivering is an adverse reaction because it indicates that the body is trying to generate heat to counteract the cooling effect of the blanket, which can increase metabolic demand and is counterproductive.
C: Flushing is typically related to fever or other causes but not directly to the adverse reaction of cooling.
D: Restlessness can be caused by discomfort or the fever itself, not specifically by cooling.
Correct Answer is D
Explanation
A. While determining if the procedure is medically necessary is important, the decision-making process should involve the client's designated surrogate, especially when the client is unable to make decisions.
B. While family support is valuable, the primary concern is ensuring that the client's designated surrogate, who is responsible for making healthcare decisions on behalf of the client, is informed and involved in the decision-making process.
C. Sending the unsigned informed consent form to the facility's risk manager does not address the immediate need to ensure that the client's healthcare surrogate is informed about the procedure and its implications.
D. When a client is unable to provide informed consent due to incapacitation, the nurse should communicate with the client's designated health care surrogate to ensure they are aware of the risks and benefits of the procedure and can make decisions on behalf of the client.
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