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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Since vitamin B12 is primarily found in animal products, clients following a vegan diet should be advised to consume fortified foods or supplements containing vitamin B12 to prevent deficiency.
B. High-fat cheese is not a suitable meat substitute for individuals following a vegan diet, as it is an animal-derived product.
C. Nuts and legumes are valuable sources of protein and other nutrients in a vegan diet and should not be limited unless there are specific dietary restrictions or preferences.
D. Foods high in vitamin C are beneficial for overall health, but limiting them is not necessary for individuals following a vegan diet.

A. "That can't be true. The only voices in this room are yours and mine." B. "You shouldn't be afraid when you think the voices are telling you to hurt yourself." C. "I understand the voices are frightening you, but I do not hear any voices." D. "Do you recognize the voices as belonging to anyone you know?"

Correct Answer is C

Explanation

A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.

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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

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Explanation

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