A nurse is providing administration instruction to the wife of a client going home on intermittent enteral nutrition. Which information should the nurse include?

Correct Answer: A

Rationale: Cleaning equipment between each enteral feeding is vital to prevent bacterial contamination, as residual formula can foster microbial growth, risking infections like gastroenteritis in a client already nutritionally compromised. While limiting hang time is important, evidence suggests a 4-hour maximum, not 8, to minimize spoilage-though this isn't the focus here. Refrigerating unused feeding preserves its integrity, preventing degradation or bacterial proliferation, which is critical for safety. Keeping the insertion site clean reduces infection risk at the tube entry, a common complication in enteral therapy. Cleaning equipment stands out as a proactive step the wife can take between feedings, directly impacting hygiene and client safety, whereas other points address storage or site care, which, while essential, are secondary to the immediate post-feeding action of equipment maintenance in this context.

Correct Answer: A

Rationale: Cleaning equipment between each enteral feeding is vital to prevent bacterial contamination, as residual formula can foster microbial growth, risking infections like gastroenteritis in a client already nutritionally compromised. While limiting hang time is important, evidence suggests a 4-hour maximum, not 8, to minimize spoilage-though this isn't the focus here. Refrigerating unused feeding preserves its integrity, preventing degradation or bacterial proliferation, which is critical for safety. Keeping the insertion site clean reduces infection risk at the tube entry, a common complication in enteral therapy. Cleaning equipment stands out as a proactive step the wife can take between feedings, directly impacting hygiene and client safety, whereas other points address storage or site care, which, while essential, are secondary to the immediate post-feeding action of equipment maintenance in this context.

Correct Answer: A

Rationale: HRT increases clotting risk, making calf pain a priority due to potential DVT, a life-threatening side effect. Libido , back pain , and fatigue are less urgent. A ensures safety, aligning with HRT risks, making it the priority.

Correct Answer: C

Rationale: A common side effect of Heparin, which is an anticoagulant medication, is the risk of bleeding. Heparin works by preventing the formation of blood clots, which can lead to a bleeding risk as it inhibits the normal clotting process. Patients taking Heparin should be monitored closely for signs of bleeding, such as easy bruising, prolonged bleeding from minor cuts, or blood in the urine or stools. It is important for healthcare providers to closely monitor patients on Heparin therapy and adjust the dosage as needed to minimize the risk of excessive bleeding.

Correct Answer: D

Rationale: Depo-Provera, a progestin injection, provides contraception by inhibiting ovulation for 3 months , requiring re-administration every 12 weeks. This duration is based on its pharmacokinetic profile, ensuring reliable hormone levels. Two months underestimates, risking unprotected gaps. Six months or 1 year overestimate, reducing efficacy mid-cycle. The nurse's accurate response (D) educates the client on timing, ensuring adherence and preventing unintended pregnancy, aligning with clinical standards for injectable contraceptives.