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 {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"}}
No explanation
Correct Answer is B
Explanation
The correct answer is B.
Choice A reason: Checking the client’s condition after the procedure involves assessment, which is a critical component of the nursing process. This task requires clinical judgment and knowledge of potential complications, which are responsibilities that cannot be delegated to assistive personnel.
Choice B reason: Assisting with ambulation is a task that can be safely delegated to assistive personnel. It is a basic care task that does not require clinical judgment and can be performed under the supervision of a nurse.
Choice C reason: Witnessing a client’s signature on the consent for the procedure is a legal and ethical responsibility that involves ensuring the client understands the procedure and is giving informed consent. This task requires a level of professional accountability that is beyond the scope of assistive personnel.
Choice D reason: Administering medication, such as atropine 30 minutes before the procedure, is a nursing intervention that requires knowledge of pharmacology and the ability to monitor for adverse effects. This is not within the scope of practice for assistive personnel and must be performed by licensed nursing staff.
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