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
The client should wear a mask during transport to prevent the spread of infectious droplets. The nurse should wear appropriate personal protective equipment (PPE) based on the precautions required for the specific client, which in this case would be a mask. The nurse does not need to wear a gown as droplet precautions do not require the use of a gown during transport.
The correct answer is choice C, the client should wear a mask during transport.
Choice A rationale:
The client wearing a gown during transport is not typically necessary for droplet precautions unless there is a risk of the gown becoming contaminated with infectious material. Gowns are primarily used to protect the healthcare worker or other patients if there is direct contact with the patient.
Choice B rationale:
While the nurse should wear a mask if they will be within close proximity to the client, the primary concern in droplet precautions is to prevent the spread of infection from the client, who is the source of the droplets.
Choice C rationale:
The client should wear a mask during transport to contain respiratory secretions and minimize the risk of droplet spread, as droplets can be disseminated by coughing, sneezing, or talking. This is a key component of source control in droplet precautions.
Choice D rationale:
Similar to choice A, the nurse wearing a gown during transport is not a standard requirement for droplet precautions unless there is anticipated contact with the patient or their environment that might result in contamination.
In summary, the primary goal of droplet precautions is to prevent the spread of infections through large respiratory droplets that are expelled by the client. Therefore, having the client wear a mask is the most effective measure among the options provided to reduce the risk of transmission during transport.
Correct Answer is B
Explanation
Apply foam handles to the client's eating utensils. This intervention can help the client grip the utensils better and improve their ability to eat.
Reasons why the other options are not answers:
Option A: Having an assistive personnel feed the client may decrease the client's autonomy.
Option C: Obtaining a referral for physical therapy may be helpful but does not address the immediate issue of difficulty with eating.
Option D: Asking the provider for a prescription for a pureed diet may not be necessary or desirable at this time.
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