A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?
Administer 200 mL of formula during the initial infusion
Give the initial feeding over 15 min.
Reconstitute the formula with tap water
Discard unused formula after 8 hr.
The Correct Answer is D
A) Administer 200 mL of formula during the initial infusion:
The initial infusion rate for continuous enteral feeding is typically started at a slower rate, often lower than 200 mL, to assess the client's tolerance and prevent complications such as aspiration or dumping syndrome.
B) Give the initial feeding over 15 min:
Continuous enteral feeding is administered slowly over an extended period, usually 24 hours, to ensure gradual delivery of nutrients and minimize the risk of complications such as aspiration or gastrointestinal intolerance. Giving the initial feeding over 15 minutes is too rapid and can lead to adverse events.
C) Reconstitute the formula with tap water:
Reconstituting enteral formula with tap water is not recommended due to the potential risk of contamination with bacteria or other pathogens. It's essential to use sterile water or water that has been specifically purified for enteral feeding to minimize the risk of infection.
D) Discard unused formula after 8 hr:
Unused formula should be discarded after 4 hours, not 8 hours, to reduce the risk of bacterial contamination and ensure the integrity of the enteral nutrition. This practice aligns with guidelines for safe enteral feeding administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Headache:
Clients with obstructive sleep apnea often experience morning headaches due to the intermittent hypoxia and hypercapnia that occur during episodes of apnea. These headaches are typically described as dull and diffuse and may improve throughout the day.
B) Nausea:
While gastrointestinal symptoms such as nausea can occur in some individuals with sleep apnea, it is not a typical or specific finding associated with this condition. Nausea may result from other causes, such as medication side effects or underlying gastrointestinal issues, rather than directly from obstructive sleep apnea.
C) Hypotension:
Obstructive sleep apnea is more commonly associated with hypertension rather than hypotension. The recurrent episodes of hypoxemia and sympathetic nervous system activation during apneic episodes can lead to systemic hypertension over time.
D) Constipation:
Constipation is not a typical finding associated with obstructive sleep apnea. While sleep apnea may contribute to fatigue and alterations in gastrointestinal motility in some individuals, constipation is not a direct consequence of this sleep disorder.
Correct Answer is C
Explanation
A. Disenfranchised grief:
Disenfranchised grief occurs when the loss experienced by an individual is not openly acknowledged or socially supported. This type of grief may occur when the relationship with the deceased is not recognized or valued by others, such as in the case of a non-traditional relationship. In this scenario, the client's grief is acknowledged but persists beyond what is considered a typical mourning period, suggesting a different type of grief.
B. Anticipatory grief:
Anticipatory grief occurs when individuals experience feelings of loss before the actual loss or death occurs. This often happens in situations where death is expected due to a terminal illness. Since the client's partner has already died, anticipatory grief does not apply in this case.
C. Prolonged grief:
This is the correct answer. Prolonged grief, also known as complicated grief, occurs when the grieving process persists over an extended period, beyond what is considered typical or socially acceptable. Individuals experiencing prolonged grief may have difficulty accepting the reality of the loss and may continue to experience intense emotions related to the loss for an extended period, often interfering with their daily functioning.
D. Uncomplicated grief:
Uncomplicated grief refers to a normal and typical response to loss that typically resolves over time. While grief is a natural response to loss, uncomplicated grief does not persist for an extended period or significantly impair the individual's ability to function in their daily life. In this scenario, the client's continued inability to accept the loss suggests that the grief may be more complex than uncomplicated grief.
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