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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Increase the suction pressure as tolerated: Increasing the suction pressure is not recommended as it can cause damage to the gastric mucosa and lead to complications such as bleeding or ulceration. The suction pressure should be set according to the healthcare provider’s orders and the manufacturer’s guidelines.

B) Flush the tube with 0.9% sodium chloride: Flushing the NG tube with 0.9% sodium chloride is an appropriate action to maintain patency and prevent clogging. This helps ensure that the tube remains functional for effective suction and reduces the risk of complications such as infection or blockage.

C) Replace the NG tube every 24 hr: Replacing the NG tube every 24 hours is unnecessary and can cause discomfort and trauma to the client. NG tubes are typically replaced only when they become clogged, dislodged, or as per the healthcare provider’s orders.

D) Position the client supine in bed: Positioning the client supine in bed is not recommended as it increases the risk of aspiration. The client should be positioned with the head of the bed elevated to reduce the risk of aspiration and promote proper drainage through the NG tube.

A. A history of being in prison B. Male gender C. Previous violent behavior D. Experiencing delusions

Correct Answer is C

Explanation

A) A history of being in prison: While a history of incarceration can be associated with a higher risk for violence, it is not as strong a predictor as previous violent behavior. Many individuals may have been incarcerated for non-violent offenses.

B) Male gender: Although males are statistically more likely to engage in violent behavior, gender alone is not the best predictor of future violence. It does not account for individual history or behavior.

C) Previous violent behavior: This is the best predictor of future violence. Individuals who have exhibited violent behavior in the past are at a significantly increased risk of future violence. This history can be a critical indicator of potential risk.

D) Experiencing delusions: While delusions can contribute to violent behavior in some cases, they are not a reliable predictor of future violence. Not all individuals experiencing delusions will act violently, and many other factors must be considered.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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