A nurse is caring for a client who is receiving enteral tube feedings of a diluted formula. Which of the following complications of enteral tube feeding should the nurse identify as a reason to administer diluted feedings to clients?

Electrolyte imbalances

Diarrhea

Constipation

Delayed gastric emptying

Answer and Explanation

The Correct Answer is B

A. Electrolyte imbalances

Administering diluted enteral feedings is not typically done to address electrolyte imbalances. Instead, monitoring the electrolyte levels in the patient's blood and adjusting the content of the enteral formula (such as adjusting the concentration of electrolytes) would be more appropriate.

B. Diarrhea

Administering diluted enteral feedings is a strategy that may be employed to prevent or manage diarrhea. High concentrations of nutrients can overwhelm the gastrointestinal tract, leading to diarrhea. Diluting the formula helps reduce the risk of this complication.

C. Constipation

Administering diluted enteral feedings is not typically done to address constipation. Management of constipation is more commonly achieved through adjustments in fiber intake, fluid intake, and medications as needed.

D. Delayed gastric emptying

Administering diluted enteral feedings is not a standard approach for addressing delayed gastric emptying. Instead, adjustments in the rate of enteral feedings or specific interventions for delayed gastric emptying, such as medication or changes in positioning, would be considered.

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Correct Answer is A

Explanation

A. Stress incontinence

Stress incontinence is the involuntary loss of urine during activities that increase intra-abdominal pressure, such as sneezing, coughing, laughing, or lifting heavy objects. In stress incontinence, the pelvic floor muscles are weakened, leading to inadequate support of the bladder and urethra. This results in leakage of urine during moments of increased pressure on the bladder.

B. Urge incontinence

Urge incontinence involves a strong and sudden urge to urinate, leading to involuntary urine loss. It is often associated with an overactive bladder and may not be related to increased abdominal pressure.

C. Overflow incontinence

Overflow incontinence occurs when the bladder is unable to empty completely, leading to constant dribbling of urine. It is often associated with conditions that obstruct urine flow, such as an enlarged prostate in men.

D. Reflex incontinence

Reflex incontinence is characterized by the involuntary loss of urine due to a reflex arc that bypasses normal control mechanisms. It is often associated with neurological conditions that affect bladder control.

A. Assign an assistive personnel to feed the client. B. Explain that the tray is here and place the client’s hands on the tray. C. Describe to the client the location of the food on the tray. D. Ask the client if she would prefer a liquid diet.

Correct Answer is C

Explanation

A. Assign an assistive personnel to feed the client.

This option involves assigning someone else to feed the client. While it may ensure that the client receives adequate nutrition, it does not promote independence. The client may prefer to feed themselves if given the opportunity.

B. Explain that the tray is here and place the client’s hands on the tray.

While explaining the presence of the tray is helpful, physically placing the client's hands on the tray is a more direct form of assistance. It takes away the opportunity for the client to explore and locate items independently.

C. Describe to the client the location of the food on the tray.

This is the correct choice. Describing the location of the food on the tray allows the client to use their remaining senses, such as touch and hearing, to independently locate and eat their food.

D. Ask the client if she would prefer a liquid diet.

This option is related to dietary preferences but does not directly address the issue of promoting independence in eating. It focuses more on the type of diet rather than the manner in which the client can independently manage their meals.

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A nurse is caring for a client who is receiving enteral tube feedings of a diluted formula. Which of the following complications of enteral tube feeding should the nurse identify as a reason to administer diluted feedings to clients?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is C

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