A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube.

Which of the following actions should the nurse plan to take?

1. Answer and explanation.

The correct answer is choice A. Increased Hct.

Hct stands for hematocrit, which is the percentage of red blood cells (RBCs) in the blood.

A client who received 2 units of packed RBCs should have an increased Hct because they have more RBCs in their blood volume. The normal range for Hct is 38% to 50% for males and 36% to 44% for females.

Choice B is wrong because decreased Hgb means decreased hemoglobin, which is the protein that carries oxygen in the RBCs.

A client who received 2 units of packed RBCs should have an increased Hgb because they have more hemoglobin in their blood. The normal range for Hgb is 13.5 to 17.5 g/dL for males and 12 to 15.5 g/dL for females.

Choice C is wrong because increased platelets means increased thrombocytes, which are the cells that help with blood clotting.

A client who received 2 units of packed RBCs should not have an increased platelet count because they did not receive platelets in the transfusion. The normal range for platelets is 150,000 to 400,000/mm^3.

Choice D is wrong because decreased WBC count means decreased leukocytes, which are the cells that fight infection and inflammation.

A client who received 2 units of packed RBCs should not have a decreased WBC count because they did not receive WBCs in the transfusion. The normal range for WBC count is 4,500 to 11,000/mm^3.

A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).

B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.

C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.

D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.

E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.

F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.