NCLEX National Council Licensure Examination(NCLEX-RN) NCLEX-RN Question # 149 Topic 15 Discussion
NCLEX-RN Exam Topic 15 Question 149 Discussion:
Question #: 149
Topic #: 15
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
A.
“If he develops diarrhea lasting for more than 2–3 days, I will contact the doctor or nurse.”
B.
“I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.”
C.
“It is important to keep the head of his bed elevated or sit him in the chair during feedings.”
D.
“I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.”
(A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (1⁄2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the client’s head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.
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