A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

Check the gastric residual every 8 hr.

Change the feeding bag every 24 hr.

Flush the tube with sterile sodium chloride solution every 2 hr.

Position the head of the client's bed at 15.

Answer and Explanation

Correct Answer : B

Correct answer: B

A. Check the gastric residual every 8 hr:
Explanation: It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.

B. Change the feeding bag every 24 hr:
Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.

C. Flush the tube with sterile sodium chloride solution every 2 hr:
Explanation: While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.

D. Position the head of the client's bed at 15 degrees:
Explanation: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration.

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Correct Answer is D

Explanation

A. 8.0: An aspirate pH of 8.0 would indicate an alkaline substance. This would not be typical of stomach contents, which are acidic. An alkaline pH might suggest placement in the intestines or respiratory tract.

B. 6.0: While this is less alkaline than 8.0, it is still not within the typical range for stomach contents. Stomach aspirate is generally more acidic.

C. 7.0: A pH of 7.0 is neutral. Stomach contents are typically more acidic, so a neutral pH would not be consistent with correct NG tube placement in the stomach.

D. 4.0: This is within the acidic range and is consistent with the pH of stomach contents. It would be considered an indication of correct NG tube placement in the stomach.

A. Provide the client with a diet high in protein. B. Massage bony prominences to promote circulation. C. Reposition the client every 3 hr. D. Apply cornstarch to keep the skin dry.

Correct Answer is A

Explanation

A.Adequate protein intake is essential for skin repair and maintaining skin integrity. Protein helps in the healing process, supports the immune system, and strengthens the skin, making it more resistant to breakdown. This is a crucial intervention for preventing pressure ulcers and promoting overall skin health in older adults.

B.Massaging bony prominences is not recommended as it can cause friction and damage to already vulnerable skin, increasing the risk of skin breakdown rather than preventing it. Gentle repositioning is preferred to relieve pressure.

C.Clients at risk for skin breakdown should typically be repositioned at least every 2 hours, not every 3 hours, to relieve pressure and reduce the risk of developing pressure ulcers. Therefore, this option is not ideal as stated.

D.While keeping the skin dry is important, cornstarch is not recommended because it can cake and cause friction, which may lead to skin breakdown. Using moisture-wicking products or barrier creams is more appropriate for maintaining skin dryness and integrity.

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A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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