The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (SELECT ALL THAT APPLY)

Solution provided

Name of physician prescribing the feeding

Client tolerance of the feeding

Amount of solution

Duration of the feeding

Answer and Explanation

Correct Answer : A,C,D,E

A. Documenting the type of solution provided for tube feeding is essential for accurate record-keeping and continuity of care. This includes specifying the name and composition of the enteral formula used, such as standard polymeric, high-protein, elemental, or specialized formulas for specific medical conditions or nutritional needs.
C. Documenting the client's tolerance of the tube feeding is crucial for monitoring their response to the enteral nutrition. This includes assessing for signs of intolerance, such as nausea, vomiting, abdominal pain, bloating, diarrhea, or aspiration. Documenting tolerance helps guide adjustments to the feeding regimen and ensures patient safety and comfort.
D. Documenting the amount of solution administered during the tube feeding is essential for accurately monitoring the client's intake and ensuring that nutritional goals are met. This includes recording the volume of formula administered, as well as any additional flushes or medications given through the feeding tube.
E. Documenting the duration of the tube feeding session provides important information about the timing and frequency of feedings. This includes recording the start and end times of the feeding, as well as any interruptions or adjustments made during the procedure. Documenting the duration helps ensure consistency in the feeding regimen and facilitates effective communication among healthcare providers.
B. Documenting the name of the physician who prescribed the tube is not necessary.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. A healthy stoma should appear moist and shiny, indicating adequate blood supply and hydration of the tissue. Dryness or dullness of the stoma may indicate poor blood flow or dehydration and should be further evaluated.
B. A healthy stoma typically appears deep pink to red in color, indicating good tissue perfusion. Pallor or cyanosis of the stoma may indicate inadequate blood supply and should be assessed promptly.
C. The skin around the stoma, known as the peristomal skin, should be intact, without signs of irritation, redness, or tenderness. Irritation or breakdown of the peristomal skin can occur due to leakage of stool or irritation from ostomy appliances and should be addressed promptly to prevent skin complications.
D. A flat abdomen suggests normal abdominal contour without distention or bulging. Distention or bulging of the abdomen may indicate underlying issues such as bowel obstruction, gas accumulation, or fluid retention and should be assessed further.

E. Bowel sounds are indicative of gastrointestinal motility and function. Normal bowel sounds are present and audible in healthy individuals and are characterized by 8 to 10 clicks or gurgles per minute. Absence or abnormal bowel sounds may indicate bowel obstruction, ileus, or other gastrointestinal disorders and should be assessed further.

A. Setting the room temperature on the colder side B. Postponing a teaching session if the client appears to be mildly anxious C. Emphasizing information that is most important first D. Allowing the client to listen to music while the teaching is taking place

Correct Answer is C

Explanation

C. Prioritizing essential information and presenting it first can increase the likelihood that the client grasps key concepts and retains important details. By focusing on the most crucial information initially, the client is more likely to understand and remember the core concepts of the teaching session. This approach helps prevent information overload and ensures that the client receives the most critical information upfront, enhancing their learning outcomes.
A. Extreme temperatures, whether too hot or too cold, can be distracting and uncomfortable for the client, potentially detracting from their ability to focus on the teaching session and retain information.

B. Postponing a teaching session if the client appears to be mildly anxious: This strategy acknowledges the importance of addressing the client's emotional state in facilitating effective learning. If a client appears to be mildly anxious or emotionally distressed, it may be beneficial to postpone the teaching session temporarily until the client feels more calm and receptive to learning. Addressing the client's emotional needs and ensuring a supportive environment can enhance their ability to engage in the teaching process and retain information effectively.
D. While some individuals may find listening to music relaxing or enjoyable, it can also serve as a distraction during a teaching session, especially if the music competes with the nurse's instructions or interferes with the client's ability to concentrate.

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The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D","E"]

Explanation

Which strategy Increases the probability that the client will achieve the knowledge of the essential information that the nurse is teaching?

Correct Answer is C

Explanation

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