A weight gain of 1 lb (approximately 0.45 kg) per day is excessive and unrealistic for lean body mass accretion. Such rapid weight gain is a significant indicator of fluid retention and potential fluid overload, which can strain the cardiovascular system. A safe and appropriate weight gain goal for a client on nutritional support is typically 0.5 to 2 lbs (0.23 to 0.9 kg) per week. This statement demonstrates a fundamental misunderstanding of the therapeutic goals and potential complications of enteral nutrition, indicating a clear need for further teaching by the nurse.

A. Reporting diarrhea that persists for more than 2-3 days is the correct action, as it can signify a significant complication requiring medical intervention to prevent dehydration and electrolyte imbalance.

C. Elevating the head of the bed to at least 30-45 degrees during and after feedings is a critical aspiration precaution that uses gravity to prevent reflux and aspiration pneumonia.

D. Opened enteral formula is a growth medium for bacteria; it should be refrigerated and discarded after 24 hours to prevent contamination and subsequent gastrointestinal infection.

1. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing (10th ed.). Elsevier.

Regarding Correct Answer (B): Chapter 45, Nutrition, discusses monitoring patient outcomes. It emphasizes that weight gain should be gradual. A rapid daily gain suggests fluid retention, a complication to be reported (p. 1135, "Monitoring for Complications").

Regarding Incorrect Option (C): Chapter 45, Nutrition, explicitly states, "A major cause of complications is aspiration of formula into the tracheobronchial tree... To prevent aspiration, allow the head of the bed to be elevated to a minimum of 30 degrees, preferably 45 degrees" (p. 1133, "Aspiration of Formula").

Regarding Incorrect Option (D): Chapter 45, Nutrition, details safe administration practices, including that the "hang time" for formula in an open system at room temperature is typically 8 hours, and any unused, opened formula must be refrigerated and discarded after 24 hours (p. 1132, Box 45.11 "Procedural Guidelines: Administering Enteral Tube Feedings").

2. Bankhead, R., Boullata, J., Brantley, S., et al. (2009). Enteral nutrition practice recommendations. Journal of Parenteral and Enteral Nutrition, 33(2), 122-167. https://doi.org/10.1177/0148607108330314

Regarding Incorrect Option (A): Section 7, "Monitoring the Patient Receiving EN," recommends monitoring for gastrointestinal tolerance, including diarrhea. It notes that if diarrhea is severe or persistent, the cause should be investigated and managed (p. 147).

Regarding Incorrect Option (C): Section 6, "Administration," recommends, "To decrease the risk of aspiration, elevate the head of the bed (HOB) to 30°-45°" (p. 144).