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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Acupuncture is typically administered by a trained acupuncturist, not by the nurse. It is not commonly initiated upon arrival at the labor unit.
Choice B rationale: Biofeedback is a technique that usually requires prior training and practice; it is not typically taught for the first time at the beginning of labor.
Choice C rationale: Transcutaneous electrical nerve stimulation (TENS) can help manage back pain during labor but is not specifically used for pelvic pressure.
Choice D rationale: Using an ultrasound picture as a focal point during contractions is a common nonpharmacological pain management technique. Focal points help the client concentrate and manage pain through visualization and distraction.
Correct Answer is A
Explanation
Choice A rationale:
Choosing a palpable and straight vein is essential for a successful IV insertion. A vein that is easily palpable and visible helps ensure that the catheter can be inserted smoothly, reducing the risk of complications such as infiltration or extravasation. Additionally, selecting a straight vein makes the insertion process easier and less painful for the client.
Choice B rationale:
Selecting a site on the client's dominant arm is not a requirement for IV insertion. The choice of arm depends on the individual client's condition, vein accessibility, and the healthcare provider's preference. Both arms can be used for IV insertion based on the client's specific needs.
Choice C rationale:
Applying a tourniquet below the venipuncture site helps distend the veins, making them more visible and accessible. This technique can aid in locating suitable veins for insertion. However, it is crucial to release the tourniquet once the vein is accessed to prevent complications such as thrombosis or hematoma.
Choice D rationale:
Elevating the client's arm prior to insertion can cause veins to collapse, making it more challenging to insert the IV catheter. Gravity can assist in distending the veins, so the arm should be positioned at or slightly below the level of the heart during IV insertion to maintain adequate blood flow.
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