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?
Elevate the head of the client's bed for 1 hr after the feeding.
Administer the feeding solution at a cold temperature.
Rotate the jejunostomy tube once per day
Flush the tube with 90 mL of sterile water before and after the feeding.
The Correct Answer is 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.
The explanation for why the other choices are not answered: 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Clients with a left-sided stroke will have neurological deficits on the right side of the body, including paralysis or weakness. Impaired speech, language, and cognition are also possible. Blood pressure, temperature, and laboratory results may be affected by the stroke, but they are not specific to a left-sided stroke.
Option A, "Blood pressure," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
Option B, "Temperature," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
Option D, "Laboratory results," is incorrect because they may be affected by the stroke, but they are not specific to a left-sided stroke.
Correct Answer is A
Explanation
Epoetin alfa is a medication used to stimulate erythropoiesis, the production of red blood cells. An increase in the client's hemoglobin level indicates that the medication has been effective. The normal range of hemoglobin for adult females is 12-16 g/dL and for adult males is 13.5-17.5 g/dL. A hemoglobin level of 11 g/dL is slightly below the normal range, but it is an improvement from a lower level. Choice B, WBC count 9,000/mm3 is unrelated to the medication and is within the normal range. Choice
C, total calcium 10 mg/dL, and choice D, PT 12 seconds, are also unrelated to the medication and are within the normal range.
Choice B (WBC count 9,000/mm3) is not an answer because it is unrelated to the medication and is within the normal range.
Choice C (total calcium 10 mg/dL) is not an answer because it is unrelated to the medication and is within the normal range.
Choice D (PT 12 seconds) is not an answer because it is unrelated to the medication and is within the normal range.
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