A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?
Check the gastric residual every 8 hr.
Change the feeding bag every 24 hr.
Flush the tube with sterile sodium chloride solution every 2 hr.
Position the head of the client's bed at 15.
Correct Answer : B
Correct answer: B
A. Check the gastric residual every 8 hr:
Explanation: It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.
B. Change the feeding bag every 24 hr:
Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.
C. Flush the tube with sterile sodium chloride solution every 2 hr:
Explanation: While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.
D. Position the head of the client's bed at 15 degrees:
Explanation: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Proliferation Phase:
Explanation: This phase involves the formation of new tissue to fill the wound space. It includes granulation tissue formation and wound contraction.
B. Inflammation Phase:
Explanation: This is the initial phase characterized by hemostasis and inflammation, aimed at stopping bleeding and preventing infection. Blood vessels constrict, platelets aggregate, and inflammatory cells arrive at the wound site.
C. Maturation Phase:
Explanation: Also known as the remodeling phase, it involves the remodeling and realignment of collagen fibers and the strengthening of scar tissue.
D. Remodeling Phase:
Explanation: Remodeling and maturation are often considered together as the final stage of wound healing, where collagen fibers reorganize and gain strength.
Correct Answer is A
Explanation
Correct answer: D
A.Wiping the top of the can before opening prevents contamination and reduces the risk of introducing pathogens into the feeding system.
B.Cold formula can cause gastric discomfort or cramping. It's recommended to bring the formula to room temperature before administration to avoid gastric irritation and enhance comfort during feeding.
C.The action of withholding the feeding depends on the institution's protocol and the specific clinical condition of the client. Typically, residuals greater than 200 mL might indicate delayed gastric emptying, but the threshold can vary. A residual volume of 150 mL may not necessarily require withholding the feeding, though it may warrant further assessment.
D.In most cases, flushing is done with tap water (if safe for drinking) or sterile water in immunocompromised clients. The key step is to flush before and after feedings, but the standard practice is not automatically sterile water for all patients.
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