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 C
Explanation
A. Ask a nursing student who speaks the same language as the client to translate: This is not appropriate, as the nursing student may not be trained in medical terminology or confidentiality, which could lead to miscommunication and potential breaches of privacy.
B. Allow the client's partner to translate: While the partner may understand the language, this approach can create conflicts of interest, and they may not be able to convey the full medical context or sensitive information accurately.
C. Request a female interpreter through the facility: This is the best action. Using a trained, professional interpreter ensures that the communication is accurate and confidential, allowing the nurse to gather necessary admission data effectively while respecting the client's comfort and cultural needs.
D. Have the client's child translate: It is not appropriate to involve a child in medical discussions, as they may not fully understand the context or terminology and could feel overwhelmed by the responsibility.
Correct Answer is A
Explanation
A. Faint pedal pulse of left leg: A faint pedal pulse indicates poor circulation and is a clear sign of altered tissue perfusion. It suggests that the blood flow to the affected extremity may be compromised, warranting immediate assessment and intervention.
B. Pain with movement of the left great toe: While pain may indicate an issue, it does not specifically indicate altered tissue perfusion. Pain can result from various causes, including injury or inflammation, but it is not a direct measure of blood flow.
C. Purulent drainage at the pin site: Purulent drainage suggests infection rather than altered perfusion. While infections can affect tissue health, this finding does not directly indicate compromised blood flow to the extremity.
D. Warm skin temperature distal to pin site: Warm skin typically suggests adequate perfusion, as warmth can indicate good blood flow. In contrast, coolness or coldness would be a more concerning sign of altered perfusion.
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