A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
Elevate the head of the client's bed for 1 hr after the feeding.
Administer the feeding solution at a cold temperature.
Rotate the jejunostomy tube once per day
Flush the tube with 90 mL of sterile water before and after the feeding.
The Correct Answer is A
Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux.
Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea.
Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site.
Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.
The explanation for why the other choices are not answered: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Breast self-examinations should be performed monthly, not every other month. This regularity helps with early detection of any changes.
Choice B rationale: Dimpling of the skin on the breasts is not common and can be a sign of breast cancer or other conditions. This statement indicates a misunderstanding.
Choice C rationale: It is indeed common for one breast to be slightly larger than the other. This is a normal variation and not usually a cause for concern.
Choice D rationale: Breast self-examinations should be performed several days after the menstrual period ends, not the day the period begins. This timing helps to reduce the likelihood of hormonal changes affecting breast tissue.
Correct Answer is ["A","D"]
Explanation
The correct answer is a. Dysuria and d. Hematuria.
Choice A rationale:
Dysuria, or painful urination, is a common symptom of cystitis due to the inflammation of the bladder lining.
Choice B rationale:
Bradycardia, or slow heart rate, is not typically associated with cystitis. Cystitis primarily affects the urinary system and does not usually impact heart rate.
Choice C rationale:
Pruritus, or itching, is not a common symptom of cystitis. Itching is more often associated with skin conditions or allergic reactions.
Choice D rationale:
Hematuria, or blood in the urine, can occur with cystitis due to the irritation and inflammation of the bladder lining.
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