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?

Flush the tube with 10 mL of water after feedings.

Discard the open can of formula after 36 hr.

Administer feedings at a slower rate.

Provide chilled formula.

Answer and Explanation

The Correct Answer is C

A.   Flushing the tube with water after feedings helps to prevent tube clogging and ensures adequate delivery of enteral feedings. However, it does not address the diarrhea.
B.   While it's important to discard open cans of formula within a specified timeframe to prevent bacterial growth, diarrhea in the client is not directly addressed by discarding formula after 36 hours.
C.   The nurse should consider administering feedings at a slower rate to manage diarrhea. This approach can help reduce the incidence of diarrhea as it allows for better absorption of the nutrients.
D.   Providing chilled formula is not typically indicated for clients with diarrhea and may not be well-tolerated.

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Correct Answer is D

Explanation

A: Feeling light-headed upon standing is a common side effect of many psychotropic medications, indicating orthostatic hypotension but not necessarily requiring immediate provider intervention unless it persists or worsens.
B: Mumbling quietly could be related to the client’s schizophrenia rather than a direct effect of the medication.
C: Photosensitivity can be a side effect of some antipsychotic medications, but it is less concerning than neurological symptoms and usually manageable with lifestyle adjustments.
D: A shuffling gait can indicate the development of parkinsonism, a serious side effect of antipsychotic medications, which involves motor impairments mimicking symptoms of Parkinson's disease. This is significant and should be reported to the provider immediately for potential medication adjustment.

A. Sims B. Supine C. Left lateral D. Low-Fowler's

Correct Answer is D

Explanation

A. The Sims position is a lateral position used for procedures such as rectal examinations and enemas and is not typically indicated for managing increased intracranial pressure.
B. The supine position may worsen increased intracranial pressure by increasing venous return and intracranial pressure.
C. The left lateral position may be used in specific circumstances, such as to relieve pressure on the vena cava in pregnancy, but it is not typically indicated for managing increased intracranial pressure.
D. Positioning the client in Low-Fowler's position (with the head of the bed elevated approximately 15-30 degrees) helps facilitate venous drainage from the brain, thereby reducing intracranial pressure. This position promotes optimal cerebral perfusion and helps manage increased intracranial pressure.

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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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