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. While documentation of sensitive material may be a responsibility of the charge nurse, it does not directly relate to educating a newly licensed nurse about the facility's computerized documentation system.
B. Securing client information through measures like installing a firewall is crucial in a computerized documentation system to maintain confidentiality and prevent unauthorized access or data breaches.
C. While password change frequency is an important aspect of maintaining system security, it is not the most critical information to convey to a newly licensed nurse regarding the documentation system.Most facilities require more frequent password changes to enhance security, such as every 60 to 90 days, to mitigate the risk of unauthorized access and potential breaches.
D. Providing access to all client records would violate privacy and security protocols and is not an accurate representation of how the documentation system operates.
Correct Answer is A
Explanation
A. When assessing skin turgor in older adults, it is recommended to perform the test over the sternum or on the forehead. This is due to the fact that many older adults have reduced skin turgor as a part of the typical aging process, which can make it difficult to use the test to determine dehydration accurately in other areas.
B. In the elderly, skin turgor assessment on the abdomen can be influenced by factors such as adipose tissue and may not provide as reliable an indicator.
C. The shoulder is not commonly used for assessing skin turgor and may not provide reliable results.
D. The neck is not typically used for assessing skin turgor and may not provide an accurate reflection of hydration status.
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