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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Constipation
This is correct. Inadequate dietary intake of fiber can lead to constipation. Fiber adds bulk to the stool and promotes regular bowel movements.
B. Memory loss
Memory loss is not typically associated with an inadequate dietary intake of fiber. It is more commonly related to other factors such as aging, medical conditions, or nutritional deficiencies.
C. Brittle hair
Brittle hair is not a direct result of an inadequate intake of dietary fiber. Hair health is influenced by various factors, including overall nutrition and hydration.
D. Bleeding gums
Bleeding gums are not directly linked to an inadequate intake of fiber. However, insufficient vitamin C intake, which is often found in fruits and vegetables (sources of fiber), can contribute to gum problems.
Correct Answer is C
Explanation
A. "Sweating can occur with hypoglycemia."
Explanation: This statement is correct. Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.
B. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: This statement is correct. Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.
C. "My son might have nausea and vomiting with hypoglycemia."Nausea and vomiting are more commonly associated with hyperglycemia, especially in diabetic ketoacidosis (DKA). They are not typical signs of hypoglycemia.
D. "The onset of low blood glucose usually occurs rapidly."Hypoglycemia often has a rapid onset, especially with missed meals or increased activity.
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