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 A
Explanation
Choice A rationale:
The anterior fontanel is open in an 8-month-old infant. The anterior fontanel, located at the top of the baby's head where the skull bones have not yet fused, typically closes between 12 to 18 months of age. It is a normal finding in an 8-month-old infant.
Choice B rationale:
The posterior fontanel closes earlier than the anterior fontanel, usually within the first few months of life. It is a smaller diamond-shaped area located at the back of the baby's head. It is not expected to be open in an 8-month-old infant.
Choice C rationale:
Molding refers to the shaping of the fetal head during passage through the birth canal. It can cause temporary changes in the shape of the baby's skull. By 8 months of age, molding is not an expected finding as the skull bones have had time to return to their normal shape.
Choice D rationale:
Both fontanels being the same size is not a typical finding. The anterior fontanel is larger than the posterior fontanel, and their sizes are proportional. Any significant deviation from this proportion could indicate abnormal skull development and should be further assessed.
Correct Answer is A
Explanation
Choice A rationale:
A 12-lead ECG (electrocardiogram) is the priority diagnostic test for a patient with symptoms suggestive of chest pain and a potential cardiac event. Chest pain and a feeling of heaviness on the chest can be indicative of various cardiac conditions, including myocardial infarction (heart attack). A 12-lead ECG provides valuable information about the heart's electrical activity, helping healthcare providers assess for signs of ischemia, arrhythmias, or myocardial infarction. Early detection and intervention are crucial in cardiac emergencies, making
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