A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse is appropriate?

Checking residual volume before each feeding

Flushing the tube with 15 mL of water

Elevating the head of the bed to a 20" angle

Adding colored food dye to the formula

Answer and Explanation

The Correct Answer is A

Rationale:
A. Checking residual volume prior to each feeding is appropriate to assess tolerance and reduce the risk of aspiration.
B. Flushing the tube should be done with at least 30 mL of water (not 15 mL) to maintain patency and prevent clogging.
C. The head of the bed should be elevated to at least 30° to 45°, not 20°, to reduce aspiration risk.
D. Adding food dye to formula is contraindicated due to the risk of adverse effects and is not evidence-based practice.

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Correct Answer is D

Explanation

Rationale:
A. Personal beliefs about family relationships are subjective and not necessary for a change-of-shift or transfer report.
B. Detailed wound care procedures belong in the medical record or care plan, not in the transfer report.
C. A client’s bathing preference is relevant to daily care but not essential for continuity of care during transfer.
D. The time of the last pain medication is critical information for continuity of care and client safety, ensuring the next care team can manage pain effectively and avoid overdosing.

A. "A family member can interpret to obtain informed consent from a client who is deaf." B. "Consent can be given by a durable power of attorney." C. "The nurse can answer any questions the client has about the procedure." D. "Guardian consent is required for an emancipated minor."

Correct Answer is B

Explanation

Rationale:
A. A qualified medical interpreter—not a family member—should be used to obtain informed consent from a client who is deaf to ensure accuracy and confidentiality.
B. A durable power of attorney for healthcare can legally provide consent on behalf of a client who is unable to make their own healthcare decisions, making this statement correct.
C. Nurses can clarify information but cannot provide new information or answer questions about risks, benefits, or alternatives—that is the provider’s responsibility.
D. Emancipated minors can provide their own consent; a guardian’s consent is not required.

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A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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