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 C

Explanation

A) Gelatin: Gelatin is a suitable choice for a clear liquid diet. It is transparent and easily digestible, making it appropriate for individuals requiring clear liquids, such as those recovering from certain medical procedures or surgeries.

B) Popsicle: Popsicles are commonly included in clear liquid diets. They provide hydration and can help soothe a sore throat or provide relief from nausea. However, it is essential to ensure that the popsicle is clear and does not contain any solid fruit or pieces.

C) Yogurt: Yogurt is not typically included in a clear liquid diet. Clear liquid diets consist of transparent or translucent fluids that are easily digested and leave minimal residue in the gastrointestinal tract. Yogurt, being a semi-solid food, contains particles that are not clear and is typically considered a full liquid or soft diet item rather than a clear liquid. Therefore, the client's choice of yogurt indicates a need for further teaching regarding appropriate food choices for a clear liquid diet.

D) Broth: Broth, such as chicken or beef broth, is a staple of clear liquid diets. It is easily digested and provides essential electrolytes and hydration. Broth can be consumed hot or cold, depending on the client's preference and medical condition.

A. The client's daughter, who is the primary caregiver B. The client C. The client's partner D. The client's son, who has a durable power of attorney

Correct Answer is B

Explanation

A. The client's daughter, who is the primary caregiver: While the daughter may be involved in the client's care and decision-making process, the client themselves should provide informed consent if they have decision-making capacity. Informed consent cannot be provided by a caregiver unless legally authorized to do so.

B. The client: The client is alert, oriented, and has advance directives. In this scenario, the client possesses decision-making capacity and is capable of providing informed consent for the procedure. As long as the client is competent and able to understand the nature, risks, benefits, and alternatives of the procedure, they are the appropriate person to sign the informed consent document.

C. The client's partner: Unless legally designated as the client's healthcare proxy or legally authorized to provide consent on the client's behalf, the partner should not sign the informed consent document. The client themselves should provide consent if they have decision-making capacity.

D. The client's son, who has a durable power of attorney: While a durable power of attorney grants legal authority to make healthcare decisions on behalf of the client if they lack decision-making capacity, it does not negate the client's ability to provide informed consent if they are competent to do so. If the client is alert, oriented, and capable of understanding the procedure, they should sign the informed consent document themselves.

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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

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?

Correct Answer is B

Explanation

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