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. Identify the clients at greatest risk for the development of pressure ulcers.
This option emphasizes the importance of individualized care. By identifying clients at the highest risk for pressure ulcers, healthcare providers can tailor preventive measures to address specific risk factors such as immobility, nutritional deficits, and skin conditions.

B. Turn and position each client every 2 hr.
Regular turning and repositioning are crucial in preventing pressure ulcers, especially in individuals with limited mobility. This helps distribute pressure, reducing the risk of skin breakdown. However, this alone may not be sufficient if other risk factors are not addressed.

C. Use a barrier cream when performing perineal care.
Barrier creams can be helpful in protecting the skin from moisture and friction, especially in areas prone to pressure ulcers. While this is a good practice, it may not be the top priority compared to identifying those at the highest risk.

D. Supervise clients to ensure adequate nutritional intake.
Proper nutrition plays a vital role in maintaining skin integrity. Malnutrition can contribute to the development of pressure ulcers. Monitoring and ensuring adequate nutritional intake are important components of prevention but may not be the initial priority.

A. Uses the ball of a finger as the puncture site B. Avoids using the fingers of her dominant hand as puncture sites. C. Uses the side of a fingertip as the puncture site D. Avoids using the thumbs as puncture sites

Correct Answer is C

Explanation

A. Using the ball of the finger (the fleshy part) is not recommended as it can lead to more pain and discomfort. The side of the fingertip is generally preferred for less discomfort and more accurate results.

B. Avoids using the fingers of her dominant hand as puncture sites:While it's generally recommended to avoid using the fingers of your dominant hand for frequent blood glucose monitoring, it's not always necessary. The client can still obtain accurate readings from her dominant hand if she rotates puncture sites.

C. Using the side of the fingertip is a recommended practice. The side of the fingertip has fewer nerve endings than the pad of the finger, which helps reduce discomfort. This technique is commonly used for more accurate and less painful blood glucose testing.

D. Avoids using the thumbs as puncture sites:
Using thumbs as puncture sites is generally avoided because they might have thicker skin and could yield less accurate blood samples. Therefore, avoiding thumbs for blood glucose testing is a good practice.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?

Correct Answer is C

Explanation

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