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 C

Explanation

The correct answer is C. Believes his bad behavior is causing his brother's death. This is an example of magical thinking, which is common among school-age children (6 to 12 years old). Magical thinking is the belief that one's thoughts or actions can influence events or outcomes that are beyond one's control. School-age children may feel guilty or responsible for their sibling's illness or death and may try to bargain or change their behavior to prevent it.

A. Heart rate 58/min. B. Fasting blood glucose 100 mg/dL. C. WBC count 2,900/mm3. D. Hgb 14 g/dL.

Correct Answer is C

Explanation

Choice A rationale:

Heart rate 58/min. Clozapine, an atypical antipsychotic medication, can cause bradycardia (slow heart rate) as a side effect. However, the heart rate of 58/min is within the normal range for adults, so it is not a contraindication for clozapine administration.

Choice B rationale:

Fasting blood glucose 100 mg/dL. A fasting blood glucose level of 100 mg/dL is within the normal range (70-99 mg/dL) for adults. It is not a contraindication for clozapine administration.

Choice C rationale:

WBC count 2,900/mm3. Clozapine can cause agranulocytosis, a severe reduction in white blood cell (WBC) count, which can lead to increased susceptibility to infections. A WBC count of 2,900/mm3 is significantly below the normal range (4,000-11,000/mm3) and is a contraindication for clozapine administration due to the risk of severe immunosuppression.

Choice D rationale:

Hgb 14 g/dL. Hemoglobin (Hgb) level of 14 g/dL is within the normal range for adult males (13.8-17.2 g/dL) and females (12.1-15.1 g/dL). It is not a contraindication for clozapine administration.

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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?

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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?