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) Premature ventricular contraction: A premature ventricular contraction (PVC) typically presents as an early heartbeat originating from the ventricles, often accompanied by a wide QRS complex. The heart rate in this case is regular at 69/min, and there is no indication of early beats, making this option unlikely.

B) First-degree AV block: A first-degree AV block is characterized by a prolonged PR interval greater than 0.20 seconds, which is noted at 0.24 seconds in this scenario. This indicates a delay in conduction through the AV node. While the heart rate is normal, the prolonged PR interval clearly suggests a first-degree AV block.

C) Atrial fibrillation: Atrial fibrillation typically presents with an irregularly irregular rhythm and variable heart rates. The client’s heart rate of 69/min is regular, and there is no mention of an irregular pulse or varying R-R intervals, making atrial fibrillation an unlikely diagnosis in this case.

D) Sinus bradycardia: Sinus bradycardia is defined as a heart rate of less than 60 beats per minute and is characterized by a normal PR interval. In this situation, the heart rate is 69/min, which does not meet the criteria for bradycardia, thus ruling out this option.

A. Ask a nursing student who speaks the same language as the client to translate. B. Allow the client's partner to translate. C. Request a female interpreter through the facility. D. Have the client's child translate.

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.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is C

Explanation

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