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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Choose orange juice instead of apple juice:
Explanation: Orange juice is a source of potassium, so this choice would not be appropriate for a low potassium diet.

B. Replace sugar with molasses when baking:
Explanation: Molasses is a good alternative to sugar and does not contribute significantly to potassium intake, making it suitable for a low potassium diet.

C. Avoid using salt substitutes when cooking:
Explanation: Salt substitutes often contain potassium chloride, which can increase potassium intake. Therefore, it's advisable to avoid them on a low potassium diet.

D. Eat granola for breakfast:
Explanation: Granola can be a good source of potassium, so it may not be suitable for someone on a low potassium diet.

A. Metoprolol 50 mg. PO daily. B. Maintain accurate intake and output records. C. Furosemide Lasix 40 mg push. D. Encourage fluid intake, more than 2000 mL/day.

Correct Answer is C

Explanation

A. Metoprolol 50 mg PO daily:
This is a beta-blocker that helps lower blood pressure and heart rate. While it may be part of managing heart failure, it is not the immediate priority in a client presenting with signs of fluid overload and congestion.

B. Maintain accurate intake and output records:
Monitoring intake and output is important in managing fluid balance.
However, in this situation, the priority is to address the existing fluid overload promptly.

C. Furosemide (Lasix) 40 mg push:
Furosemide is a loop diuretic that promotes the excretion of excess fluid. Administering it "push" implies a more rapid onset of action, making it suitable for addressing acute fluid overload.

D. Encourage fluid intake, more than 2000 mL/day:
In the context of fluid overload, encouraging additional fluid intake is contraindicated. The focus should be on removing excess fluid with diuretic therapy rather than promoting more intake.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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