Answer to Question 1
A
A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs to verify tube placement and elevate the head of the bed 30 to 45 degrees during feedings and for 2 hours afterward. The addition of blue food coloring to enteral formula to assist with detection of aspirate is no longer used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium for bacterial growth after that length of time.
Answer to Question 2
A
Deep-breathing and coughing exercises place additional stress on the suture line and cause dis-comfort. Splinting the incision with hands or a pillow provides firm support and reduces inci-sional pulling.
Keeping the client flat will not decrease discomfort in the incisional area when the client coughs. Having the client bend his or her knees slightly will aid in relaxing the abdominal muscles, causing less discomfort.
Turning the client onto the right side will not decrease discomfort in the incisional area when the client coughs. The client should turn from side to side at least every two hours and may splint the incision to decrease discomfort when doing so.
Applying pressure above and below the incision is not the correct measure. Splinting should be done directly over the incision to provide firm support and reduce incisional pulling as the client coughs postoperatively.
A, A nurse is adding a medication to an IV line as a piggyback
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Risk assessment codes for an HIV-infected patient.