A nurse is teaching the partner of a client about administering intermittent enteral feedings. Which of the following instructions should the nurse include?
Wear sterile gloves during a feeding.
Chill the feeding prior to administering.
Flush the tubing with 15 mL of water after each feeding.
Position the client upright prior to a feeding.
The Correct Answer is C
Choice C reason: Flushing the tubing with water after each feeding is important to prevent clogging, maintain patency, and clear any residual formula from the tube. It also helps to prevent bacterial growth and infection.
Choice A reason: Wearing sterile gloves during a feeding is not necessary, as enteral feedings are not considered sterile procedures. Clean gloves are sufficient to prevent contamination and protect the nurse and the client.
Choice B reason: Chilling the feeding prior to administering is not recommended, as cold formula can cause abdominal cramping, discomfort, and diarrhea. The formula should be at room temperature or slightly warmed before giving it to the client.
Choice D reason: Positioning the client upright prior to a feeding is correct, but it is not enough. The client should remain upright for at least 30 minutes after the feeding as well, to prevent aspiration, reflux, and nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these changes to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these changes to the provider as well, but they are not the most urgent ones.
Choice C reason: Clear lungs bilaterally are a normal finding and do not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Choice D reason: A soft and non-tender abdomen is a normal finding and does not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Correct Answer is B
Explanation
Choice B reason: Lentils are a rich source of folate, which is a B vitamin that is essential for the development of the neural tube and the prevention of neural tube defects in the fetus . One cup of cooked lentils provides about 358 micrograms of folate, which is 90% of the recommended daily intake for pregnant women.
Choice A reason: Mashed potatoes are not a good source of folate, as they contain only 8 micrograms of folate per cup, which is 2% of the recommended daily intake for pregnant women. Potatoes are mainly a source of carbohydrates, potassium, and vitamin C.
Choice C reason: Green peppers are a moderate source of folate, as they contain 42 micrograms of folate per cup, which is 11% of the recommended daily intake for pregnant women. Green peppers are also a source of vitamin C, vitamin A, and fiber.
Choice D reason: Carrots are a low source of folate, as they contain 24 micrograms of folate per cup, which is 6% of the recommended daily intake for pregnant women. Carrots are mainly a source of vitamin A, beta-carotene, and fiber.
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