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:
Documenting the desire to be an organ donor in writing is a legal requirement and ensures that the individual's wishes are respected after their passing. It also provides clear guidance to healthcare providers and family members about the individual's decision.
Choice B rationale:
There is no specific age requirement to become an organ donor. People of various ages can register as organ donors, and eligibility often depends on the condition of the organs at the time of death.
Choice C rationale:
Once someone is listed as an organ donor, their name can be removed if they change their mind. It's essential for individuals to inform their family members about their decision and ensure their wishes are respected.
Choice D rationale:
The nurse can indeed be a witness for the consent to donate. Being a witness ensures the authenticity of the individual's decision to become an organ donor and can be helpful in legal and ethical contexts.
Correct Answer is []
No explanation
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