A nurse is caring for a client who has a small-bore jejunostomy and is receiving a continuous tube feeding with a high-viscosity formula. Which of the following actions should the nurse take to prevent the tubing from clogging?

Correct Answer: B

Rationale: The correct answer is B) Flush the tubing with 10 mL water every 6 hours. This action helps prevent clogging of the tubing by ensuring that the high-viscosity formula does not solidify and block the tube. Flushing with water helps maintain tube patency and keeps the formula flowing smoothly, reducing the risk of complications for the client. Option A) Replace the bag and tubing every 24 hours is incorrect because simply changing the tubing does not address the issue of preventing clogging due to high-viscosity formula. It is important to focus on tube maintenance to prevent clogs. Option C) Administering the feeding by gravity drip does not directly address the prevention of tubing clogging. The method of administration does not impact the viscosity of the formula or the likelihood of clogging. Option D) Heating the formula prior to infusion may be necessary for some formulas but does not specifically address the prevention of tubing clogging. Heating may help with formula consistency but does not replace the need for regular flushing to prevent clogs. In an educational context, it is crucial for nurses to understand the importance of tube maintenance in clients receiving enteral feedings. Regular flushing of the tubing with water helps prevent clogs, ensuring the safe delivery of nutrition to the client. Nurses should be knowledgeable about best practices for enteral feeding to provide optimal care and prevent complications.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) 1 scrambled egg, which is equivalent to 1 oz of protein. A scrambled egg provides a complete source of protein, containing all essential amino acids crucial for toddler growth and development. It is important for parents to understand the value of protein in their child's diet to support muscle growth, tissue repair, and overall health. Option A) 2 tbsp peanut butter is incorrect as it is a source of fat and protein, but 2 tbsp do not equate to 1 oz of protein. Option B) ½ cup peas is incorrect as peas are a vegetable source of protein, but ½ cup does not provide 1 oz of protein. Option C) 1 slice of bread is incorrect as bread is primarily a source of carbohydrates and does not contain a significant amount of protein. Educationally, it is essential for parents to be knowledgeable about the nutritional needs of their toddlers to ensure they receive adequate protein for growth and development. By understanding which foods are good sources of protein, parents can make informed decisions when planning their child's meals to promote optimal health and well-being.

Correct Answer: D

Rationale: In this scenario, the correct menu selection for a client who follows the dietary laws of Orthodox Judaism would be option D) Grilled vegetables. The rationale behind this choice lies in the dietary restrictions of Orthodox Judaism, which prohibit the consumption of certain foods such as pork and shellfish. Pork sausage (option C) and broiled shrimp (option B) are not permissible according to these dietary laws due to the prohibition of eating pork and shellfish. On the other hand, grilled vegetables (option D) are a safe and suitable choice as they align with the dietary guidelines of Orthodox Judaism. Vegetables are generally considered permissible and can be consumed by individuals following this dietary practice. From an educational perspective, this question highlights the importance of cultural and religious considerations in providing care to clients. Understanding and respecting a client's dietary preferences and restrictions are crucial in delivering culturally competent care. By selecting appropriate food options that align with a client's beliefs and practices, nurses can promote positive outcomes and enhance the overall quality of care provided.

Correct Answer: B

Rationale: In caring for a client with stomatitis following radiation treatment, offering mouth rinses with normal saline and water (Option B) is the most appropriate intervention. This intervention helps to clean the oral cavity, soothe inflamed tissues, and promote healing. Normal saline has a gentle cleansing effect without causing further irritation, making it a safe and effective choice for oral hygiene in this situation. Option A, serving foods without sauces or gravies, is incorrect because these types of foods may be irritating to the inflamed oral tissues and can worsen discomfort. Option C, serving hot foods, is also inappropriate as heat can exacerbate the client's symptoms and should be avoided. Option D, instructing the client to drink liquids without a straw, is not directly related to managing stomatitis and does not address the specific needs of the client in this situation. Educationally, it is crucial for nurses to understand the principles of managing stomatitis, especially in clients undergoing radiation treatment. Providing evidence-based care, like using normal saline mouth rinses, demonstrates the nurse's competency in promoting oral health and comfort for clients experiencing stomatitis. By selecting the appropriate intervention, nurses can contribute to better outcomes and quality of life for their clients undergoing radiation therapy.

Correct Answer: A

Rationale: In the context of a client with Clostridium difficile, experiencing Fluid Volume Deficit, the correct lab finding indicating this condition is an elevated Hematocrit (Hct) level of 53%. Hematocrit measures the proportion of red blood cells in the blood, and an elevated level can indicate hemoconcentration due to dehydration associated with fluid volume deficit. Option B, Potassium level of 3.5, is not indicative of fluid volume status but rather reflects the electrolyte balance. Option C, Sodium level of 145, is within normal range and does not specifically indicate fluid volume deficit. Option D, HbA1c level of 5, is a measure of long-term blood sugar control in diabetes and is not relevant to fluid volume status. Educationally, understanding how different lab values reflect a client's fluid volume status is crucial for nurses to assess and intervene appropriately in cases of dehydration or fluid imbalances, especially in conditions like Clostridium difficile where fluid losses can be significant. This knowledge aids in providing effective care and preventing complications related to fluid volume deficits.