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 D
Explanation
Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 and a decrease in pH.
Analysis:
pH 7.22: Indicates acidemia (pH below 7.35), suggesting acidosis.
PaCO2 68 mm Hg: Elevated PaCO2 indicates hypoventilation, which is characteristic of respiratory acidosis.
Base excess -2: Base excess is within normal limits and does not contribute significantly to the acid-base imbalance in this scenario.
PaO2 78 mm Hg: PaO2 is slightly low but not significantly contributing to the acid-base imbalance.
Saturation 80%: Oxygen saturation is low, indicating hypoxemia, which is commonly associated with respiratory acidosis due to hypoventilation.
Bicarbonate 26 mEq/L: Bicarbonate is within normal limits, suggesting compensation for the respiratory acidosis, which is a chronic condition.
Overall, the ABG values indicate respiratory acidosis due to inadequate ventilation, leading to CO2 retention and subsequent acidemia.
Correct Answer is B
Explanation
A) Utilitarianism: Utilitarianism focuses on the greatest good for the greatest number of people. In this scenario, the nurse's decision not to administer the pain medication is not based on maximizing overall benefit but rather on avoiding harm to the individual client.
B) Non-maleficence: Non-maleficence is the ethical principle of doing no harm. The nurse's decision not to administer the pain medication is rooted in the desire to avoid causing harm to the client by potentially hastening their death.
C) Fidelity: Fidelity refers to the obligation to fulfill commitments and responsibilities. While important, fidelity is not directly relevant to the nurse's decision in this scenario.
D) Veracity: Veracity refers to truthfulness and honesty. While honesty is crucial in communicating with the client and their family about their condition and care, it is not the primary ethical principle guiding the nurse's decision in this situation.
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