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) The statement about returning to school once the fever has subsided is not sufficient for varicella. Children should not return until the lesions have crusted over to prevent spreading the infection.

B) The recommendation that the child can return to school once the lesions have crusted over is accurate. Varicella is contagious from 1 to 2 days before the rash appears until all lesions have crusted over, which usually occurs about 6 days after the onset of the rash.

C) A negative titer result is not necessary for a child to return to school. Immunity can be confirmed through vaccination history or prior infection; thus, this statement is misleading.

D) Since varicella is a viral infection, antibiotics are not indicated for treatment. Therefore, stating that the child can return to school 24 hours after beginning antibiotics is incorrect and could lead to misunderstanding about the management of the illness.

A. Apply petroleum jelly to soothe the mucous membranes. B. Clean the equipment with an alcohol-based cleaning product. C. Avoid using nail polish remover around the client. D. Use synthetic fabrics for the client's bedding.

Correct Answer is C

Explanation

A) Apply petroleum jelly to soothe the mucous membranes: This is not advisable, as petroleum jelly is flammable and can pose a risk when using oxygen. Instead, a water-based lubricant is safer for mucous membranes.

B) Clean the equipment with an alcohol-based cleaning product: Alcohol is flammable and not recommended for cleaning oxygen equipment. Mild soap and water are more suitable for maintaining cleanliness.

C) Avoid using nail polish remover around the client: This is the correct answer. Nail polish remover often contains acetone, which is flammable and should be avoided in environments where oxygen is in use to prevent fire hazards.

D) Use synthetic fabrics for the client's bedding: This is incorrect. Natural fabrics like cotton are preferred because synthetic fabrics can create static electricity, increasing the risk of fire in the presence of oxygen.

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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 C

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