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.
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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Related Questions
Correct Answer is C
Explanation
The correct answer is C. Believes his bad behavior is causing his brother's death. This is an example of magical thinking, which is common among school-age children (6 to 12 years old). Magical thinking is the belief that one's thoughts or actions can influence events or outcomes that are beyond one's control. School-age children may feel guilty or responsible for their sibling's illness or death and may try to bargain or change their behavior to prevent it.
Correct Answer is C
Explanation
Step 1: Convert the dopamine hydrochloride dose from mcg to mg. We know that 1 mg = 1000 mcg. So, 4 mcg = 0.004 mg.
Step 2: Calculate the total amount of dopamine hydrochloride the client needs per minute. We know that the client weighs 80 kg and the dose is 0.004 mg/kg/min. So, 0.004 mg/kg/min × 80 kg = 0.32 mg/min.
Step 3: Convert the total amount of dopamine hydrochloride the client needs per minute to an hourly rate. We know that 1 hour = 60 minutes. So, 0.32 mg/min × 60 min/hr = 19.2 mg/hr.
Step 4: Calculate the volume of the solution that contains 19.2 mg of dopamine hydrochloride. We know that the solution contains 800 mg in 250 mL. So, (19.2 mg ÷ 800 mg) × 250 mL = 6 mL.
Therefore, the nurse should set the IV infusion to deliver 6 mL/hr (rounded to the nearest whole number).
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