A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

The correct answer is choice A: Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux. Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea. Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site. Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.

Explanation for why the other choices are not answers: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.

The correct answer is choice D. The nurse should identify an oral temperature of 39°C (102.2°F) as the priority finding in a client who is postoperative following a total thyroidectomy for hyperthyroidism. An elevated temperature can indicate infection, which is a risk after surgery. The nurse should report this finding to the provider immediately.

Choices A, B, and C are incorrect because moderate amount of serosanguineous drainage on dressings, serum calcium level 9.2 mg/dL, and report of a sore throat, respectively, are expected findings after a total thyroidectomy and do not require immediate action.