A nurse is caring for a client who is receiving enteral feedings through a nasogastric tube and has developed diarrhea. Which of the following actions should the nurse take?

Add water during tube flushes

Change to an enteral formula that has added fiber.

Slow down the instillation flow rate.

Add yogurt to enteral feedings.

Answer and Explanation

The Correct Answer is C

A. Add water during tube flushes: Adding water during tube flushes is important for maintaining tube patency and hydration but does not directly address diarrhea. It is not a primary solution for managing diarrhea caused by enteral feedings.

B. Change to an enteral formula that has added fiber: While fiber can help regulate bowel movements, changing to a formula with added fiber is not the first intervention for diarrhea. A slow-down of the feeding rate may be more effective to allow the digestive system more time to process the formula.

C. Slow down the instillation flow rate: Slowing down the flow rate of the enteral feeding can reduce the likelihood of diarrhea. A rapid infusion rate can overwhelm the intestines and lead to diarrhea, so adjusting the flow rate is an appropriate first step.

D. Add yogurt to enteral feedings: While yogurt contains probiotics that might help with gut health, adding it to the feeding may not be advisable unless specifically indicated. The primary step for managing diarrhea is adjusting the flow rate of the feeding.

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Correct Answer is A

Explanation

A. Use a standardized approach to giving the handoff report: Using a standardized approach, such as SBAR (Situation, Background, Assessment, Recommendation), ensures that all necessary information is communicated clearly and systematically.

B. Encourage the oncoming shift nurse to contact the provider with any questions: The primary focus of the handoff report should be to provide the oncoming nurse with all necessary information. Directly contacting the provider should not be a primary strategy.

C. Provide the handoff report at the nurses' station: Providing a report at the nurses' station may not be private or conducive to clear communication. It is better to conduct the report in a private area or at the client’s bedside to ensure confidentiality and clarity.

D. Record a verbal report on a recorder for the oncoming nurse to listen to: Recorded reports are not ideal for ensuring continuity of care because they lack the interactive aspect of handoff, such as clarifying questions or addressing concerns in real time.

A. Projection B. Sublimination C. Rationalization D. Dissociation

Correct Answer is C

Explanation

A. Projection: Projection involves attributing one’s own undesirable feelings or thoughts onto others. This is not applicable here, as the client is not projecting their behavior onto someone else.

B. Sublimation: Sublimation is the process of channeling negative or unacceptable impulses into socially acceptable activities. Smoking due to anxiety is not an example of channeling impulses into a productive or acceptable activity.

C. Rationalization: Rationalization is a defense mechanism where a person justifies or makes excuses for their behavior or feelings. In this case, the client is justifying smoking as a way to manage anxiety, which is a classic example of rationalization.

D. Dissociation: Dissociation involves a detachment from reality or a separation of thoughts, identity, or consciousness, typically as a coping mechanism in response to trauma or stress. It is not applicable in this situation, where the client is not detaching from reality.

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A nurse is caring for a client who is receiving enteral feedings through a nasogastric tube and has developed diarrhea. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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