A nurse is caring for a client who is receiving enteral feedings through a nasogastric tube and has developed diarrhea. Which of the following actions should the nurse take?
Add water during tube flushes
Change to an enteral formula that has added fiber.
Slow down the instillation flow rate.
Add yogurt to enteral feedings.
The Correct Answer is C
A. Add water during tube flushes: Adding water during tube flushes is important for maintaining tube patency and hydration but does not directly address diarrhea. It is not a primary solution for managing diarrhea caused by enteral feedings.
B. Change to an enteral formula that has added fiber: While fiber can help regulate bowel movements, changing to a formula with added fiber is not the first intervention for diarrhea. A slow-down of the feeding rate may be more effective to allow the digestive system more time to process the formula.
C. Slow down the instillation flow rate: Slowing down the flow rate of the enteral feeding can reduce the likelihood of diarrhea. A rapid infusion rate can overwhelm the intestines and lead to diarrhea, so adjusting the flow rate is an appropriate first step.
D. Add yogurt to enteral feedings: While yogurt contains probiotics that might help with gut health, adding it to the feeding may not be advisable unless specifically indicated. The primary step for managing diarrhea is adjusting the flow rate of the feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Let me clarify that you want the medication given gid, correct?": When receiving a telephone prescription, it is essential to clarify any unclear aspects of the order, such as the dosage frequency. This ensures that the prescription is accurately understood and implemented and helps prevent medication errors.
B. "Will you please spell the name of that medication for me?": Although confirming the medication name is important, it is more critical to clarify the specific directions for administering the medication, such as the frequency, rather than spelling.
C. "I will sign my name now and leave a space for you to sign your name.": Offering to leave a space for the provider's signature is standard practice. However, it's not the most critical communication safety check during the verbal order itself.
D. "Let me provide you with the client's medical record number for identification.": While important for ensuring correct patient identification, the nurse should first focus on accurately obtaining the medication prescription and other critical details before providing identification information.
Correct Answer is A
Explanation
A. Use a standardized approach to giving the handoff report: Using a standardized approach, such as SBAR (Situation, Background, Assessment, Recommendation), ensures that all necessary information is communicated clearly and systematically.
B. Encourage the oncoming shift nurse to contact the provider with any questions: The primary focus of the handoff report should be to provide the oncoming nurse with all necessary information. Directly contacting the provider should not be a primary strategy.
C. Provide the handoff report at the nurses' station: Providing a report at the nurses' station may not be private or conducive to clear communication. It is better to conduct the report in a private area or at the client’s bedside to ensure confidentiality and clarity.
D. Record a verbal report on a recorder for the oncoming nurse to listen to: Recorded reports are not ideal for ensuring continuity of care because they lack the interactive aspect of handoff, such as clarifying questions or addressing concerns in real time.
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