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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Requesting additional information about the caller's relationship to the client does not ensure the caller's identity is verified, and it could still result in a breach of confidentiality.
Choice B rationale: Providing a general update about the client's condition over the telephone is not appropriate, as it could breach the client's confidentiality.
Choice C rationale: Referring the family member to the client's provider for the update respects confidentiality and ensures that information is only provided to authorized individuals, maintaining the client's privacy.
Choice D rationale: Encouraging the family member to contact the client directly for information ensures that the client has control over their own information and maintains confidentiality. This action respects the client's privacy and autonomy.
Correct Answer is C
Explanation
Choice A rationale:
Expressing concern about another shift's holiday hours does not necessarily involve interpersonal conflict. It may reflect dissatisfaction but doesn't involve direct conflict between individuals.
Choice B rationale:
A personal difficulty with caring for clients who have HIV could be a challenge for the nurse, but it's not an example of interpersonal conflict. It represents a personal struggle rather than a conflict with another individual.
Choice C rationale:
Insulting comments directed at a nurse by another nurse represent interpersonal conflict. Such behavior involves a direct clash of personalities and can create a hostile work environment, affecting the nurse's well-being and job performance. Addressing this type of conflict is crucial for maintaining a positive work atmosphere.
Choice D rationale:
Submitting a complaint about another department's handoff reporting might indicate dissatisfaction or concerns about workflow, but it's not necessarily an interpersonal conflict. It could be a communication issue or a difference in professional opinion rather than a direct clash between individuals.
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