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 C

Explanation

A. Cimetidine:Cimetidine can indeed increase the effect of metformin due to competition for renal tubular clearance. This can lead to higher levels of metformin in the blood and potentially increase the risk of side effects. While it does not directly contraindicate metformin use, monitoring and dose adjustments might be necessary to manage this interaction.

B. Cephalexin:
Cephalexin is an antibiotic used to treat bacterial infections. It does not have a significant impact on blood glucose levels and is not contraindicated for a client taking metformin.

C. Prednisone:This is a corticosteroid that can increase blood glucose levels. Corticosteroids are known to cause hyperglycemia and may impair glucose control, which can be problematic for someone with diabetes taking metformin.

D. Levothyroxine:
Levothyroxine is a medication used to treat hypothyroidism. It does not have a direct impact on blood glucose levels and is not contraindicated for a client taking metformin.

A. Report of decreased urinary output B. Random blood glucose 126 mg/dL C. Clammy skin D. History of poor wound healing

Correct Answer is D

Explanation

A. Report of decreased urinary output
Explanation: Decreased urinary output is not typically associated with hyperglycemia. In fact, increased urinary output (polyuria) is more characteristic.

B. Random blood glucose 126 mg/dL
Explanation: This level is within the normal range for random blood glucose. Hyperglycemia is usually defined by higher blood glucose levels.

C. Clammy skin
Explanation: Clammy skin is not a direct manifestation of hyperglycemia. Symptoms of hyperglycemia may include increased thirst, frequent urination, and blurred vision.

D. History of poor wound healing
Explanation: This is correct. Hyperglycemia can contribute to impaired wound healing, as it affects the body's ability to repair tissues.

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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

A nurse is collecting data from a client who takes metformin for type 2 diabetes. Which of the following medications is contraindicated for this client due its effect on blood glucose levels?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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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?