A nurse is caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take?
Provide chilled formula.
Administer feedings at a slower rate.
Discard the open can of formula after 36 hr.
Flush the tube with 10 mL of water after feedings.
The Correct Answer is B
A. Provide chilled formula: Chilled formula can be less palatable and may cause gastrointestinal discomfort, potentially worsening diarrhea. Room temperature or slightly warmed formula is generally recommended for enteral feedings to enhance tolerance and digestion.
B. Administer feedings at a slower rate: Slowing the rate of enteral feedings can help reduce gastrointestinal irritation and improve absorption, which may be particularly beneficial for a client experiencing diarrhea. This approach allows the intestines more time to process the nutrients, potentially alleviating symptoms.
C. Discard the open can of formula after 36 hr: While proper storage is important, many enteral formulas can be stored for up to 48 hours once opened. The key is to ensure the formula is stored correctly to prevent bacterial growth, but the 36-hour guideline may not be strictly necessary in all cases.
D. Flush the tube with 10 mL of water after feedings: Flushing the tube is a good practice to maintain tube patency, but the volume may not be adequate depending on the tube size and the specific protocol. Adequate flushing is essential, but it does not directly address the issue of diarrhea, which is the priority concern in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) FHR baseline 170/min: A fetal heart rate (FHR) baseline of 170 beats per minute is considered tachycardia and can indicate fetal distress or maternal complications, such as fever or dehydration. This finding requires prompt reporting to the provider for further evaluation and intervention.
B) Early decelerations in the FHR: Early decelerations are typically benign and associated with head compression during contractions. They are not indicative of fetal distress and do not require immediate reporting.
C) Contractions lasting 80 seconds: While contractions that last longer than 90 seconds can indicate potential complications, 80 seconds is still within a manageable range. However, monitoring for patterns is essential, but it does not require urgent reporting unless there are other concerning signs.
D) Temperature 37.4° C (99.3° F): This temperature is within the normal range for a laboring woman and does not indicate infection or other complications. It is not a critical finding that necessitates reporting to the provider.
Correct Answer is D
Explanation
A. Face: While jaundice can sometimes be observed on the face, it is not the most reliable area for assessment in clients with dark skin, as changes may be less visible due to pigmentation.
B. Palms of the hands: The palms can show signs of jaundice, but they may not be the best area to assess for this condition in clients with darker skin tones. Jaundice is typically more detectable in areas with less pigmentation.
C. Shoulders: The shoulders do not provide a reliable assessment area for jaundice, as skin tone can vary widely and may obscure subtle changes in color.
D. Sclera: The sclera (the white part of the eye) is the most appropriate area to assess for jaundice, regardless of skin color. Yellowing of the sclera is a classic sign of jaundice and can be easily observed in clients with dark skin.
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