A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system.
Which of the following interventions should the nurse include in the plan of care?
Maintain bed elevation at 20 degrees.
Flush the tubing with 30 mL of water every 4 hr.
Check for gastric residual every 12 hr.
Place enough formula in the container to last 18 hr.
The Correct Answer is B
The correct answer is Choice B.
Choice A rationale: Maintaining bed elevation at 20 degrees is not recommended. The recommended bed elevation for patients receiving enteral tube feedings is at least 30 to 45 degrees. This is to prevent aspiration of the feeding solution into the lungs.
Choice B rationale: Flushing the tubing with 30 mL of water every 4 hours is a recommended practice. This helps to maintain the patency of the feeding tube and prevent clogging.
Choice C rationale: Checking for gastric residual every 12 hours is not sufficient. For patients receiving continuous tube feedings, gastric residual volume (GRV) should be monitored every 4 hours. This helps to assess tolerance to the feeding and prevent complications such as aspiration.
Choice D rationale: Placing enough formula in the container to last 18 hours is not recommended. For an open system, the formula should be replaced every 4 hours to prevent bacterial growth.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Allowing the client to have time alone in their room might provide some relief, but it does not address the caregiver's overall stress and the impact on their life. Moreover, constant isolation is not a healthy solution for the client, as social interaction is essential for their well-being.
Choice B rationale:
Discussing methods of communication with the client about resolving problem behaviors is a helpful approach. Effective communication strategies can reduce misunderstandings and challenging behaviors, easing the burden on the caregiver. This choice demonstrates a proactive approach to improving the caregiver's situation.
Choice C rationale:
Assisting the caregiver in arranging for a daycare program for the client is an excellent solution. Adult daycare programs provide a safe and stimulating environment for individuals with Alzheimer's disease, allowing caregivers to have some respite while ensuring the well-being of their loved ones. This choice addresses both the client's needs and the caregiver's stress, making it the most appropriate option.
Choice D rationale:
Suggesting that the caregiver seek a prescription for an antipsychotic medication for the client is not the best course of action without a thorough evaluation by a healthcare provider. Antipsychotic medications have side effects and are typically prescribed based on the client's specific symptoms and needs. Additionally, prescribing medications is beyond the nurse's scope of practice and should be determined by a healthcare provider after a comprehensive assessment.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"}}
No explanation
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