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 C
Explanation
A. Determine the need for additional providers: Determining the need for additional providers is typically the responsibility of the hospital administration or incident command team, not the unit nurse.
B. Act as a spokesperson to provide information to the media: Communication with the media is managed by designated public relations personnel or a hospital spokesperson, not the unit nurse.
C. Recommend to the provider a list of clients for early discharge: The unit nurse is responsible for assessing which clients are stable enough for discharge and communicating these recommendations to the provider. This helps prioritize bed availability and ensures appropriate allocation of resources during a disaster.
D. Decide which clients should be transported for a higher level of care: This decision is typically made by the disaster management team or the provider, with input from the nurse. Nurses may report clinical details to help inform the decision but do not make the final determination.
Correct Answer is ["A","B","C"]
Explanation
The presence of more frequent headaches and difficulty sleeping, coupled with a significant increase in blood pressure (BP 169/91 mm Hg), could suggest potential adverse effects of the medication phenelzine, which is known to cause headaches and hypertensive reactions. It is crucial for the nurse to monitor these symptoms closely, as they may require medical attention and could indicate the need for an adjustment in the client's treatment plan. The client's vital signs should be regularly monitored, and any new or worsening symptoms should be reported to the healthcare provider promptly to ensure the client's safety and well-being.
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