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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) Administer and teach about medications to suppress stage III sleep:
Suppressing stage III sleep is not a primary intervention for sleepwalking and could potentially disrupt the client’s overall sleep quality.

B) Encourage the child to verbalize feelings regarding sleep pattern:
While understanding feelings about sleep patterns may be helpful, it is not the immediate priority in managing sleepwalking.

C) Provide a quiet environment for nighttime sleep:
A quiet environment is generally beneficial for good sleep hygiene but does not directly address the safety concerns associated with sleepwalking.

D) Maintain patient safety during episodes of somnambulism:
Ensuring the client’s safety is the primary focus. Sleepwalking can lead to accidents or injuries; therefore, implementing safety measures to prevent harm during episodes of somnambulism is crucial. This may include securing the environment, using safety gates, and ensuring the client’s immediate surroundings are safe.

A. Halitosis B. Sordes C. Bruxism D. Xerostomia

Correct Answer is C

Explanation

A) Halitosis: Halitosis refers to bad breath, which may or may not be related to bruxism. While teeth grinding can contribute to dental issues that may lead to halitosis, it is not the primary disorder associated with teeth grinding.
B) Sordes: Sordes refers to the accumulation of foul-smelling crusts or deposits around the teeth and gums, typically seen in individuals with poor oral hygiene or compromised oral health. It is not directly related to teeth grinding.
C) Bruxism: Bruxism refers to the habit of grinding or clenching the teeth, especially during sleep. It can lead to dental problems, jaw pain, headaches, and other issues related to the temporomandibular joint (TMJ). Referring the client to a dentist for evaluation and management of bruxism is appropriate to address the underlying dental concerns associated with teeth grinding.
D) Xerostomia: Xerostomia, also known as dry mouth, is a condition characterized by reduced saliva production. While xerostomia may exacerbate dental problems and contribute to oral discomfort, it is not specifically associated with teeth grinding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What would be the primary focus of interventions for a client who sleepwalks?

Correct Answer is D

Explanation

A client tells the nurse that he suspects that he grinds his teeth at night. The nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

Correct Answer is C

Explanation

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