A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?
Administer 200 mL of formula during the initial infusion
Give the initial feeding over 15 min.
Reconstitute the formula with tap water
Discard unused formula after 8 hr.
The Correct Answer is D
A) Administer 200 mL of formula during the initial infusion:
The initial infusion rate for continuous enteral feeding is typically started at a slower rate, often lower than 200 mL, to assess the client's tolerance and prevent complications such as aspiration or dumping syndrome.
B) Give the initial feeding over 15 min:
Continuous enteral feeding is administered slowly over an extended period, usually 24 hours, to ensure gradual delivery of nutrients and minimize the risk of complications such as aspiration or gastrointestinal intolerance. Giving the initial feeding over 15 minutes is too rapid and can lead to adverse events.
C) Reconstitute the formula with tap water:
Reconstituting enteral formula with tap water is not recommended due to the potential risk of contamination with bacteria or other pathogens. It's essential to use sterile water or water that has been specifically purified for enteral feeding to minimize the risk of infection.
D) Discard unused formula after 8 hr:
Unused formula should be discarded after 4 hours, not 8 hours, to reduce the risk of bacterial contamination and ensure the integrity of the enteral nutrition. This practice aligns with guidelines for safe enteral feeding administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 and a decrease in pH.
Analysis:
pH 7.22: Indicates acidemia (pH below 7.35), suggesting acidosis.
PaCO2 68 mm Hg: Elevated PaCO2 indicates hypoventilation, which is characteristic of respiratory acidosis.
Base excess -2: Base excess is within normal limits and does not contribute significantly to the acid-base imbalance in this scenario.
PaO2 78 mm Hg: PaO2 is slightly low but not significantly contributing to the acid-base imbalance.
Saturation 80%: Oxygen saturation is low, indicating hypoxemia, which is commonly associated with respiratory acidosis due to hypoventilation.
Bicarbonate 26 mEq/L: Bicarbonate is within normal limits, suggesting compensation for the respiratory acidosis, which is a chronic condition.
Overall, the ABG values indicate respiratory acidosis due to inadequate ventilation, leading to CO2 retention and subsequent acidemia.
Correct Answer is B
Explanation
B) Placing clean linen that touched the floor in the soiled linen bag: This action demonstrates an understanding of infection control principles because it prevents cross-contamination between clean and soiled linens. Placing clean linens that have come into contact with the floor in the soiled linen bag reduces the risk of spreading pathogens and maintains a clean environment for the client.
A) Placing the soiled linen on the floor before bagging it: This action increases the risk of contamination by exposing the linen to potentially contaminated surfaces. Placing soiled linen on the floor can spread pathogens and is not consistent with infection control practices.
C) Holding the soiled linen against her body while carrying it to the linen bag: This action increases the risk of contamination to the AP's clothing and skin. Contact with soiled linen can transfer pathogens to the caregiver's body, leading to the potential spread of infection.
D) Shaking the soiled linen to remove any toilet paper remnants: This action can aerosolize fecal matter and spread pathogens into the air and onto nearby surfaces. Shaking soiled linen increases the risk of contamination and is not recommended as part of infection control practices.
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