A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system.
Which of the following interventions should the nurse include in the plan of care?

Maintain bed elevation at 20 degrees.

Flush the tubing with 30 mL of water every 4 hr.

Check for gastric residual every 12 hr.

Place enough formula in the container to last 18 hr.

Answer and Explanation

The Correct Answer is B

The correct answer is Choice B.

Choice A rationale: Maintaining bed elevation at 20 degrees is not recommended. The recommended bed elevation for patients receiving enteral tube feedings is at least 30 to 45 degrees. This is to prevent aspiration of the feeding solution into the lungs.

Choice B rationale: Flushing the tubing with 30 mL of water every 4 hours is a recommended practice. This helps to maintain the patency of the feeding tube and prevent clogging.

Choice C rationale: Checking for gastric residual every 12 hours is not sufficient. For patients receiving continuous tube feedings, gastric residual volume (GRV) should be monitored every 4 hours. This helps to assess tolerance to the feeding and prevent complications such as aspiration.

Choice D rationale: Placing enough formula in the container to last 18 hours is not recommended. For an open system, the formula should be replaced every 4 hours to prevent bacterial growth.

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Correct Answer is C

Explanation

Choice A rationale:

Offering small amounts of clear liquids 6 hours following surgery is generally appropriate, but it doesn't specifically address the child's pain management. Pain control is essential postoperatively, and the best approach is to administer analgesics as prescribed by the healthcare provider.

Choice B rationale:

Applying a warm compress to the operative site once daily can provide comfort and may help reduce localized pain or swelling. However, this alone might not be sufficient for pain management, especially in the immediate postoperative period.

Choice C rationale:

(Correct Choice) Administering analgesics on a scheduled basis for the first 24 hours is essential for managing postoperative pain effectively. Pain can interfere with the child's recovery, breathing, and overall well-being. Scheduled pain medications ensure a consistent level of pain relief, allowing the child to rest and recover more comfortably.

Choice D rationale:

Cromolyn nebulized solution is used to prevent asthma symptoms and allergic reactions. It is not typically indicated for postoperative pain management. Providing appropriate analgesics, as prescribed, is the standard of care for managing pain in a postoperative child.

A. aPTT. B. Platelet count. C. Fibrinogen level. D. INR.

Correct Answer is D

Explanation

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A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system. Which of the following interventions should the nurse include in the plan of care?

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A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system.
Which of the following interventions should the nurse include in the plan of care?