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 C
Explanation
Choice A rationale:
Baked potato chips are a healthier alternative to regular potato chips because they contain less fat due to the baking process. However, they are still a processed snack and might not be the healthiest option, especially for a school-age group. The high sodium content in many baked chips is also a concern for cardiovascular health.
Choice B rationale:
A milkshake made with whole milk might provide essential nutrients like calcium and protein, but it is also high in calories and can be loaded with sugar, especially if additional sugars or syrups are added. Consuming sugary beverages in excess can contribute to weight gain and dental issues.
Choice C rationale:
"Air-popped popcorn." This is the correct answer. Air-popped popcorn is a healthy whole-grain snack option. It is low in calories, high in fiber, and can be a good source of antioxidants. It is important to note that while air-popped popcorn is healthy, adding excessive butter, salt, or sugar can diminish its nutritional value.
Choice D rationale:
Cheesecake is a rich, high-calorie dessert that is not considered a healthy snack option. It is high in saturated fats, sugars, and calories, making it an occasional treat rather than a suitable healthy snack choice for school-age children.
Correct Answer is B
Explanation
The correct answer is Choice B: Speak in a normal voice at a natural pace.
Choice A rationale: Directing statements to the interpreter is inappropriate because it can make the client feel excluded from the conversation. The focus of communication should be on the client, and the interpreter is present only to facilitate understanding between the nurse and the client. Direct eye contact and addressing the client directly is important for establishing rapport and trust.
Choice B rationale: Speaking in a normal voice at a natural pace is crucial when working with an interpreter to ensure accurate translation and comprehension. It provides the interpreter with enough time to accurately convey the message while maintaining a conversational flow. Speaking too fast or in an unnatural tone can create confusion and lead to misinterpretation, ultimately affecting the quality of care provided to the client.
Choice C rationale: Using gestures while speaking with the client may not be helpful when working with an interpreter. Gestures may be culturally specific and can lead to misunderstandings or misinterpretations. Furthermore, the interpreter may not be able to accurately convey the intended message through gestures, leading to communication errors.
Choice D rationale: Pausing in the middle of sentences is not recommended when working with an interpreter. This practice can disrupt the flow of the conversation, confuse the interpreter, and lead to incomplete translations. It is essential to speak in complete sentences and provide pauses between sentences to enable the interpreter to accurately translate the information to the client.
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