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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A blood pressure reading of 150/92 mm Hg is indicative of hypertension, a symptom of preeclampsia, but it is not a therapeutic effect of magnesium sulfate.
B. A flushed face is not a therapeutic effect of magnesium sulfate and may indicate adverse effects such as magnesium toxicity.
C. A pulse rate of 100/min is within the normal range and is not a specific therapeutic effect of magnesium sulfate.
D. Negative clonus, assessed by dorsiflexing the client's foot and observing for absence of rhythmic oscillations or beats, indicates a therapeutic level of muscle relaxation provided by magnesium sulfate to prevent seizures in clients with preeclampsia
Correct Answer is D
Explanation
A: Sedation is not typically required for PICC line insertion; local anesthesia is usually sufficient.
B: An MRI is not the standard method to verify PICC line placement; an x-ray is typically used.
C: Using gauze to secure an arm board can restrict circulation and is not recommended for securing a PICC line.
D: Measuring the arm circumference daily is important to monitor for complications such as swelling or phlebitis at the insertion site.
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