A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.
For safe administration, the nurse should:

Hold the feeding if the client has soft brown stools and is passing flatus.

Dilute each medication with 5% dextrose in water (D5W) and flush with at least 30 mL.

Discuss the order with the prescriber if the client's abdomen is distended with hypoactive bowel sounds and RLQ tenderness.

Check for residual enteral formula prior to administration.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.

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Correct Answer is A

Explanation

Choice A rationale

Automatisms, such as eye blinking and lip smacking, are repetitive, involuntary movements commonly associated with absence seizures. They occur due to brief interruptions in consciousness during seizure activity without major motor involvement.

Choice B rationale

Neurotoxin exposure typically presents with symptoms like weakness, ataxia, and autonomic dysfunction. Increased eye blinking and lip smacking are not specific to neurotoxin-related neurological damage or poisoning.

Choice C rationale

Hyponatremia causes confusion, lethargy, and muscle cramps due to electrolyte disturbance affecting cellular function, but it does not cause specific automatisms like eye blinking or lip smacking in seizure-related conditions.

Choice D rationale

Reversible adverse effects of anticonvulsants often include sedation or cognitive slowing. Automatisms such as blinking and smacking are not typically linked to the pharmacological effects of anticonvulsants.

Correct Answer is ["0.1"]

Explanation

Step 1 is (225 mcg ÷ 1000 mcg) × 0.50 tablets.

Answer is 0.1 tablets.

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A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.For safe administration, the nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes increased eye blinking and lip smacking in a client who has a history of absence seizures.The nurse is aware these symptoms indicate:

Correct Answer is A

Explanation

A nurse is caring for a client who has heart failure and a prescription for digoxin 225 mcg PO daily. Available is digoxin PO 0.50 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.1"]

Explanation

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A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.
For safe administration, the nurse should: