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.
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Related Questions
Correct Answer is C
Explanation
A. "I will allow the position my mother finds most comfortable during the feeding."
This statement does not provide specific guidance on the proper positioning for enteral feedings. It's important to follow recommended positions to prevent complications.
B. "I will turn my mother on her left side during the feeding."
Turning the client on the left side is not a recommended position for enteral feedings. The head of the bed is usually elevated to 30-45 degrees to prevent aspiration.
C. "I will position the head of the bed 45 degrees during the feeding."
This is the correct choice. Elevating the head of the bed to 45 degrees helps prevent aspiration and facilitates proper flow of enteral feedings into the stomach.
D. "I will elevate the head of the bed 10 degrees during the feeding."
While some elevation is better than lying flat, the recommended angle is usually 30-45 degrees to minimize the risk of regurgitation and aspiration.
Correct Answer is ["C","D"]
Explanation
A. The patient uses crutches with a swing-to gait.
This action doesn't necessarily indicate a concern after hip arthroplasty. However, the nurse might want to assess the patient's gait and the use of crutches to ensure the proper technique is being employed and that the patient feels comfortable and stable.
B. The patient sits straight up on the edge of the bed.
Sitting straight up on the edge of the bed may not be suitable immediately after hip arthroplasty, especially with the posterior approach. The nurse should assess the patient's ability to sit upright without putting excessive pressure or strain on the surgical site.
C. The patient bends over the sink while brushing teeth.
Bending over can put stress on the surgical site and should be avoided during the initial recovery period after hip arthroplasty. This action might strain the incision and affect the healing process.
D. The patient leans over to pull on shoes and socks.
Similar to bending over the sink, leaning over to put on shoes and socks can strain the hip joint and surgical site. This movement could potentially put stress on the incision and hinder the healing process.
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