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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Placing the soiled linen on the floor before bagging it is unsanitary and violates infection control principles. It increases the risk of spreading pathogens to other surfaces, potentially contaminating the environment.

B. Placing clean linen that touched the floor in the soiled linen bag prevents cross-contamination and maintains cleanliness. It adheres to infection control standards by ensuring that only soiled items are disposed of appropriately.

C. Holding the soiled linen against her body while carrying it to the linen bag risks transferring pathogens to the caregiver's clothing and skin, compromising personal hygiene and promoting contamination.

D. Shaking the soiled linen to remove any toilet paper remnants is ineffective and hazardous. It disperses potentially infectious particles, increasing the risk of contamination and compromising infection control efforts.

A. Administer and teach about medications to suppress stage III sleep. B. Encourage the child to verbalize feelings regarding sleep pattern. C. Provide a quiet environment for nighttime sleep. D. Maintain patient safety during episodes of somnambulism.

Correct Answer is D

Explanation

A) Administer and teach about medications to suppress stage III sleep:
Suppressing stage III sleep is not a primary intervention for sleepwalking and could potentially disrupt the client’s overall sleep quality.

B) Encourage the child to verbalize feelings regarding sleep pattern:
While understanding feelings about sleep patterns may be helpful, it is not the immediate priority in managing sleepwalking.

C) Provide a quiet environment for nighttime sleep:
A quiet environment is generally beneficial for good sleep hygiene but does not directly address the safety concerns associated with sleepwalking.

D) Maintain patient safety during episodes of somnambulism:
Ensuring the client’s safety is the primary focus. Sleepwalking can lead to accidents or injuries; therefore, implementing safety measures to prevent harm during episodes of somnambulism is crucial. This may include securing the environment, using safety gates, and ensuring the client’s immediate surroundings are safe.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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