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 A

Explanation

Recent exposure to tuberculosis. This is the priority data that the nurse should address as it puts other clients and hospital staff at risk of contracting tuberculosis. Options B, C, and D are not urgent and can be addressed after addressing option A.

Reasons why the other options are not answers:

Option B: A history of generalized anxiety disorder is not an urgent issue that requires the nurse's immediate attention.

Option C: Reports periodic migraine headaches are not an urgent issue that requires the nurse's immediate attention.

Option D: Experiencing nocturia is not an urgent issue that requires the nurse's immediate attention.

A. Brain natriuretic peptide 275 pg/mL B. Calcium 9.0 mg/dL C. Sodium 140 mEq/L D. Potassium 4.0 mEq/L

Correct Answer is A

No explanation

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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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