A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?
Measure the client's gastric residual before each feeding.
Change the bag and tubing every 24 hr.
Document intake and output.
Flush the tubing with 30 mL of water after each feeding.
The Correct Answer is A
The correct answer is Choice A - Measure the client's gastric residual before each feeding.
Choice A rationale:
The nurse's first action in caring for a client receiving intermittent enteral feedings should be to measure the client's gastric residual before each feeding. Gastric residual volume helps assess the client's tolerance to enteral feedings and can indicate delayed gastric emptying or potential complications like aspiration. If the residual volume is high, the nurse can collaborate with the healthcare team to determine whether to hold the feeding, adjust the feeding rate, or take other appropriate actions to ensure the client's safety and optimal nutritional status.
Choice B rationale:
Changing the enteral feeding bag and tubing every 24 hours is important to maintain the sterility and integrity of the feeding system. However, it is not the first action the nurse should take. The priority is to assess the client's tolerance to the feeding by measuring gastric residuals, which helps prevent complications.
Choice C rationale:
Documenting intake and output is a crucial aspect of nursing care for all clients, including those receiving enteral feedings. However, in the context of intermittent enteral feedings, measuring gastric residuals before each feeding is a more immediate and specific action to ensure the client's safety and well-being.
Choice D rationale:
Flushing the tubing with 30 mL of water after each feeding is important to prevent clogging and maintain the patency of the enteral feeding tube. However, this action is secondary to measuring gastric residuals, which directly assesses the client's tolerance to the feedings and helps prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Rinsing forearms with running water before applying soap is not a recommended step in the handwashing procedure. The primary step is to wet the hands, apply soap, and create a lather.
Choice B rationale:
Holding hands above elbow level while washing and rinsing is not a standard practice for handwashing. The hands should be washed thoroughly, and the focus is on scrubbing the hands, not their positioning.
Choice C rationale:
Generating a lather by rubbing hands together vigorously for 5 seconds is insufficient for effective handwashing. Proper handwashing involves rubbing hands together for at least 20 seconds to ensure thorough cleaning.
Choice D rationale:
The correct answer. After washing and drying hands, turning off the faucet with a clean paper towel is recommended to avoid recontaminating the clean hands. Touching the faucet directly with clean hands could potentially transfer pathogens back onto the hands.
Correct Answer is A
Explanation
The correct answer is choice a. "It must be difficult facing this type of surgery.”
Choice A rationale: This statement acknowledges the client’s feelings and provides emotional support, which is crucial in reducing anxiety and promoting a sense of understanding and empathy.
Choice B rationale: While this statement aims to reassure the client, it may come off as dismissive of the client’s unique concerns and feelings, potentially making them feel invalidated.
Choice C rationale: Although this statement highlights the facility’s reputation, it does not directly address the client’s immediate emotional needs or concerns about the surgery.
Choice D rationale: Offering a sleeping pill addresses the symptom (inability to sleep) but does not address the underlying anxiety or emotional distress the client is experiencing. Emotional support is often more effective in such situations.
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