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 A

Explanation

A. Proteinuria:
Minimal change nephrotic syndrome is characterized by increased permeability of the glomerular filtration barrier, leading to proteinuria. The loss of proteins, especially albumin, in the urine is a key feature.

B. Hypocalcemia:
Hypocalcemia is not typically associated with MCNS. In fact, the loss of proteins, including albumin, in the urine can lead to decreased oncotic pressure in the blood vessels, resulting in edema. However, calcium levels are usually within the normal range.

C. Hyperalbuminemia:
This is not a characteristic finding in minimal change nephrotic syndrome. In fact, the condition is associated with hypoalbuminemia due to the loss of albumin in the urine.

D. Positive for Ketones:
Ketones are not typically associated with minimal change nephrotic syndrome. Ketones in the urine are more commonly associated with conditions like diabetic ketoacidosis or starvation.

A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. B. Irrigate the wound with an antiseptic prior to obtaining the specimen. C. Include intact skin at the wound edges in the culture. D. Swab an area of skin away from the wound to identify normal flora.

Correct Answer is A

Explanation

A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
This is a correct action. Cleaning the wound with a sterile solution, such as 0.9% sodium chloride, helps minimize contamination and ensures a more accurate culture.

B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
Using antiseptics directly on the wound before obtaining a specimen can interfere with the culture results. It's essential to use a non-bacteriostatic solution for cleaning.

C. Include intact skin at the wound edges in the culture.
The culture should focus on the material within the wound itself rather than including intact skin. The goal is to identify the specific pathogens causing the infection.

D. Swab an area of skin away from the wound to identify normal flora.
The specimen should be taken directly from the wound site to identify the pathogens responsible for the infection. Swabbing away from the wound won't provide relevant information.

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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?

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