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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Chin tuck alters airway mechanics, reducing aspiration risk by improving epiglottic closure and minimizing passage of food into respiratory pathways.
Choice B rationale
Pureeing protein may ease swallowing but does not inherently reduce aspiration risk compared to specific swallowing techniques.
Choice C rationale
Unsupervised snack access increases aspiration risk, as dysphagia requires monitored intake to prevent respiratory complications.
Choice D rationale
Background music may provide relaxation but does not scientifically mitigate aspiration risks in dysphagia-related interventions. .
Correct Answer is ["D","E"]
Explanation
Choice A rationale
Weekly appointments to change the catheter are unnecessary unless specifically indicated. Most urinary catheters are changed monthly or as needed based on physician's discretion or complications.
Choice B rationale
Sexual intimacy is possible with an indwelling urinary catheter if handled properly. Providing education on safe practices promotes normalcy and quality of life for the patient.
Choice C rationale
Wearing underwear is recommended to protect the catheter and minimize risk of contamination or accidental dislodgement. This information supports proper hygiene and comfort.
Choice D rationale
Regular emptying of the leg bag every 4 hours or more frequently prevents overfilling, which could lead to backflow and increased risk of urinary tract infections.
Choice E rationale
Foul-smelling, cloudy urine can indicate infection such as a urinary tract infection. Prompt reporting ensures early treatment and prevention of complications.
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