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 C

Explanation

A. Circulatory overload is characterized by symptoms such as dyspnea, crackles, and increased blood pressure, rather than localized redness and warmth.
B. Extravasation refers to the leakage of IV fluid into surrounding tissue, causing swelling and pain.
C. Redness and warmth around the peripheral catheter insertion site are indicative of phlebitis, which is inflammation of the vein. It's essential to document this finding accurately to monitor for worsening or complications.
D. Infiltration occurs when IV fluid leaks into the surrounding tissue, but it typically presents with swelling, pallor, and coolness at the site rather than redness and warmth.

A. Set up the sterile field 5 cm (2 in) below waist level. B. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. C. Open the outermost flap of the sterile kit toward the body. D. Place the cap from the solution sterile side up on a clean surface.

Correct Answer is D

Explanation

A: The sterile field should be set up at or above waist level to prevent contamination from higher surfaces, not below.
B: The outer edge (about 2.5 cm or 1 inch) of the sterile field is considered non-sterile, so placing the sterile dressing close to the edge risks contamination.

C: The outermost flap of the sterile kit should be opened away from the body to avoid reaching over the sterile field, which could lead to contamination.
D: The cap should be placed sterile side up to maintain its sterility if it needs to be reapplied to the solution bottle.

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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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