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 B

Explanation

A) Reduced respiratory rate:
Acute pain typically triggers an increased respiratory rate rather than a reduced one. Pain activates the sympathetic nervous system, leading to increased respiratory effort as the body prepares to fight or flee.

B) Elevated blood pressure:
Elevated blood pressure is a common physiological response to acute pain. Pain activates the sympathetic nervous system, leading to the release of stress hormones like adrenaline, which constrict blood vessels and increase heart rate and blood pressure.

C) Constricted pupils:
Pain often causes pupil dilation rather than constriction. The body's fight-or-flight response to pain involves pupil dilation to enhance visual acuity and peripheral vision, allowing individuals to detect potential threats in their environment.

D) Decreased heart rate:
Acute pain typically results in an increased heart rate rather than a decreased one. Pain triggers the release of adrenaline, which increases heart rate as part of the body's stress response to prepare for action.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30" to 45". D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.

B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.

C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.

D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.

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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

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Explanation

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Correct Answer is C

Explanation

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