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 A
Explanation
A. Flushing the NG tube with 0.9% sodium chloride helps maintain patency and prevents obstruction. It is a standard practice to flush NG tubes before and after administering medications or feedings.
B. NG tubes are not routinely replaced every 24 hours unless there is a specific clinical indication to do so.
C. The position of the client depends on the clinical situation, but supine position alone does not address NG tube care.
D. Suction pressure should be set according to the physician's orders and the patient's tolerance, but it should not be increased arbitrarily without clinical indication.
Correct Answer is B
Explanation
A. Informing the client that their name cannot be removed once listed may deter individuals from considering organ donation. In reality, individuals can update or revoke their consent at any time.
B. Organ donation requires documented consent, either through advance directives or donor registry enrollment. Verbal consent alone is not sufficient. The nurse should educate the client about the importance of documenting their wishes regarding organ donation.
C. Declaring that the nurse cannot be a witness for consent is inaccurate. Witnesses may be required depending on local regulations, but healthcare professionals can serve as witnesses.
D. Specifying a minimum age requirement for organ donation is incorrect. Organ donation eligibility depends on various factors beyond age, such as overall health and the condition of organs at the time of death.
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