A nurse is caring for a client who is receiving continuous enteral nutrition and is experiencing diarrhea. Which of the following actions should the nurse take?
Warm the formula to room temperature before infusing.
Increase the rate of infusion.
Change to a low-calorie formula if diarrhea persists.
Replace the extension tubing every 48 hr.
The Correct Answer is A
Choice A reason: Warming the formula to room temperature can help reduce the osmotic load and prevent diarrhea in clients receiving enteral nutrition. Cold formula can also cause abdominal cramping and discomfort.
Choice B reason: Increasing the rate of infusion can worsen diarrhea by increasing the osmotic load and the risk of bacterial overgrowth. The rate of infusion should be adjusted based on the client's tolerance and nutritional needs.
Choice C reason: Changing to a low-calorie formula is not indicated for diarrhea. Low-calorie formulas are usually high in osmolality and can cause more water to be drawn into the intestinal lumen, leading to diarrhea. A low-residue or isotonic formula may be more appropriate.
Choice D reason: Replacing the extension tubing every 48 hr is not enough to prevent diarrhea. The extension tubing should be replaced every 24 hr or with each new container of formula to reduce the risk of bacterial contamination and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Dentures should be stored in a container with water or a denture-cleaning solution to prevent drying and warping, not in a dry container.
B. Wrapping gloved fingers with gauze provides a better grip when removing dentures, reducing the risk of dropping them and ensuring a safe and hygienic removal process.
C. Flossing is not necessary for dentures, as they do not have natural tooth structures requiring interdental cleaning. Instead, dentures should be brushed with a soft-bristled brush.
D. A soft-bristled toothbrush, not a washcloth, should be used to clean dentures to effectively remove plaque and food debris.
Correct Answer is B
Explanation
Choice B reason: Providing low-fat carbohydrates with meals can help reduce nausea and vomiting in clients who have equilibrium imbalance. Low-fat carbohydrates are easy to digest and can provide energy and prevent hypoglycemia. Examples of low-fat carbohydrates are crackers, toast, rice, and noodles.
Choice A reason: Serving hot foods at mealtime is not a good strategy for clients who have nausea from equilibrium imbalance. Hot foods can have strong odors and flavors that can trigger nausea and vomiting. Cold or room-temperature foods are more tolerable and less stimulating for the senses.
Choice C reason: Encouraging the client to eat even if nauseated is not a helpful strategy for clients who have nausea from equilibrium imbalance. Forcing the client to eat can worsen nausea and vomiting and cause discomfort and distress. The nurse should respect the client's preferences and appetite and offer small, frequent meals and snacks.
Choice D reason: Limiting fluid intake between meals is not a necessary strategy for clients who have nausea from equilibrium imbalance. Fluid intake is important to prevent dehydration and electrolyte imbalance, which can occur due to vomiting. The nurse should encourage the client to drink fluids between meals, but avoid drinking fluids with meals, as this can cause bloating and fullness.
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