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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Dehydration is a state of insufficient fluid intake or excessive fluid loss, leading to electrolyte imbalances and increased concentrations of solutes in the blood. The elevated sodium level (hypernatremia) and slightly elevated glucose level in the context of dehydration are consistent with the laboratory findings. Dehydration can also cause elevated BUN due to decreased kidney perfusion and impaired renal function secondary to hypovolemia. Therefore, dehydration is the most likely condition based on the laboratory findings.
A. SIADH is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia (low sodium levels). In this case, the sodium level is elevated, which is not consistent with SIADH. Therefore, SIADH is unlikely.
B. Low-protein diet is not typically associated with the laboratory findings presented. Low protein intake would not directly cause elevated sodium, potassium, glucose, or BUN levels. Therefore, this option is unlikely.
D. Renal failure is characterized by impaired kidney function, resulting in electrolyte imbalances, elevated BUN, and abnormal creatinine levels. However, the creatinine level in this case is within the normal range, suggesting preserved kidney function. Additionally, the elevated sodium level is not typically associated with renal failure. Therefore, renal failure is less likely.
Correct Answer is D
Explanation
D. While considering the opinions of the deceased when making decisions may reflect a continued emotional connection to the deceased partner, it does not necessarily indicate unresolved grief. Many individuals maintain a sense of connection to deceased loved ones and may consider their perspectives or values when making decisions, even after a significant amount of time has passed since the loss. This behavior can be a way of honoring the memory of the deceased and integrating their influence into decision-making processes.
A. Attending grief support group meetings indicates that the client is actively seeking support and processing their grief in a supportive environment. This behavior is consistent with healthy grieving and can contribute to the process of grief resolution by providing opportunities for validation, sharing experiences, and receiving support from others who have experienced similar losses.
B. Being future-oriented and able to discuss the details of everyday life suggests that the client is able to focus on present and future aspects of life, rather than being consumed by grief. This can be a positive sign of adaptation and adjustment to life without the deceased partner. It indicates that the client is able to engage in activities of daily living and plan for the future, which are important aspects of grief resolution.
C. Grief is a complex and individual process that often involves periods of intense emotions, including waves of grief triggered by reminders of the deceased loved one. Experiencing occasional waves of grief triggered by pictures or events is a common experience in the grieving process and does not necessarily indicate unresolved grief. Instead, it reflects the ongoing nature of grief and the client's emotional connection to the deceased.
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