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 C

Explanation

Choice A rationale

While bleeding could indicate trauma, EEG does not detect blood presence or volume but instead evaluates electrical brain activity indicative of neuronal function.

Choice B rationale

Cerebral oxygen intake assessment requires pulse oximetry or arterial blood gas analysis rather than EEG, which monitors electrical signals, not oxygenation status.

Choice C rationale

EEG identifies abnormal brain wave patterns suggesting ongoing seizure activity, even in sedated patients, aiding in targeted interventions and preventing potential complications.

A. Stabilize the cervical spine until help arrives. B. Control any external bleeding. C. Use the head tilt chin lift method to maintain the airway. D. Do not move the victim from the accident.

Correct Answer is A

Explanation

Choice A rationale

Stabilizing the cervical spine prevents further spinal injury in case of vertebral damage, which is a priority when managing trauma patients until specialized medical care becomes available.

Choice B rationale

While controlling bleeding is essential, it is secondary to stabilizing the cervical spine since the airway and neurological protection take precedence in trauma protocols.

Choice C rationale

The head tilt chin lift method should not be used if cervical spine injury is suspected, as it may exacerbate potential damage to the vertebrae or spinal cord.

Choice D rationale

While not moving the victim is critical, stabilization of the cervical spine is the primary intervention to prevent further injury before emergency assistance arrives.

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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:

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Correct Answer is C

Explanation

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Correct Answer is A

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: