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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Hypotension. B. Dyspnea. C. Dry cough. D. Tachycardia.

Correct Answer is B

Explanation

The correct answer is choice B: Dyspnea.

Choice B rationale: Dyspnea, or difficulty breathing, is a potential indication of a recurrent pulmonary embolism and should be reported immediately. Early detection and intervention are crucial to prevent life-threatening complications.

Choice A rationale: Hypotension may be a concerning finding in postoperative clients, but it is not the priority for a client with a history of pulmonary embolism. Hypotension could be related to various factors like bleeding or anesthesia effects.

Choice C rationale: Dry cough may occur as a result of irritation or inflammation in the airway due to the surgical procedure or anesthesia. Although it should be monitored, it is not the highest priority in this situation.

Choice D rationale: Tachycardia can be a common postoperative finding due to pain, anxiety, or other factors. Although it should be monitored and addressed, it is not the most critical concern in this case. Dyspnea is more closely related to a possible pulmonary embolism and should be reported promptly.

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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?