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 B
Explanation
Choice A reas on: Weight gain of 0.45 kg (1 lb) per week is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended weight gain for this client is 0.35 to 0.5 kg (0.8 to 1 lb) per week.
Choice B reason: Intake of 200 extra calories per day is within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended caloric intake for this client is 2200 to 2900 calories per day, which is about 340 to 450 calories more than the pre-pregnancy intake.
Choice C reason: Intake of 100 extra calories per day is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended caloric intake for this client is 2200 to 2900 calories per day, which is about 340 to 450 calories more than the pre-pregnancy intake.
Choice D reason: Weight gain of 0.91 kg (2 lb) per week is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended weight gain for this client is 0.35 to 0.5 kg (0.8 to 1 lb) per week.
Correct Answer is A
Explanation
Choice A reason: Acute stress causes an increase in metabolism, as the body activates the sympathetic nervous system and releases hormones such as adrenaline and cortisol. These hormones increase the heart rate, blood pressure, and oxygen consumption, and mobilize glucose and fatty acids for energy. The nurse should explain to the clients that acute stress can have beneficial effects, such as enhancing alertness, memory, and performance, but it can also have harmful effects, such as impairing digestion, immunity, and growth.
Choice B reason: Stress causes a negative nitrogen balance in the body, not a positive one. Nitrogen balance is the difference between the amount of nitrogen ingested and the amount of nitrogen excreted. A positive nitrogen balance means that the body is retaining more nitrogen than it is losing, which indicates growth, healing, or pregnancy. A negative nitrogen balance means that the body is losing more nitrogen than it is retaining, which indicates malnutrition, illness, or injury. The nurse should inform the clients that stress can cause a negative nitrogen balance, as the body breaks down protein for energy and loses nitrogen through urine, sweat, and wounds.
Choice C reason: Protein requirements increase in times of stress, not decrease. Protein is essential for tissue repair, immune function, and hormone synthesis. The nurse should advise the clients that stress can increase the protein needs of the body, as the body loses protein through catabolism, inflammation, and infection. The nurse should recommend the clients to consume adequate amounts of high-quality protein, such as eggs, milk, cheese, meat, fish, poultry, soy, and nuts.
Choice D reason: Glucose is broken down more quickly during times of stress, not more slowly. Glucose is the main source of energy for the brain and the muscles. The nurse should educate the clients that stress can increase the glucose levels in the blood, as the body releases glucose from the liver and muscles to provide fuel for the stress response. The nurse should also warn the clients that chronic stress can lead to insulin resistance, diabetes, and cardiovascular disease.
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