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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

"Sitting quietly near the bedside can provide comfort and support." The nurse's response should provide appropriate comfort and support to the dying client's family, and sitting quietly near the bedside can provide just that.

Options A, C, and D are incorrect because medicating the client to wake them up or to minimize drowsiness is not appropriate as it interferes

A. "The virus cannot spread to areas other than the genital area." B. "The lesions may reoccur in times of stress." C. "I am only contagious while the lesions are present." D. "I can have unprotected sex as long as I am taking acyclovir."

Correct Answer is B

Explanation

"The lesions may reoccur in times of stress." This statement indicates that the client understands that the virus can reactivate and cause new outbreaks during times of stress.

Choice A is not correct because thevirus can spread to other areas through skin-to-skin contact.

Choice C is not correct because the virus can still be contagious even when no lesions are present.

Choice D is not correct because having unprotected sex can still transmit the virus even while taking acyclovir.

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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?

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