A nurse is administering continuous enteral feedings for a client through a percutaneous esophageal gastrostomy (PEG) tube. Which of the following actions should the nurse take?
Check gastric residuals every 8 hr.
Return gastric contents if residual is less than 250 mL.
Measure the pH of gastric residual every 24 hr.
Flush the tube with 15 mL of water every 4 hr.
The Correct Answer is D
Choice A reason: Checking gastric residuals every 8 hr is not frequent enough, as it can miss signs of delayed gastric emptying, which can cause aspiration, nausea, vomiting, or abdominal distension. Gastric residuals should be checked every 4 hr.
Choice B reason: Returning gastric contents if residual is less than 250 mL is not advisable, as it can increase the risk of infection, contamination, or electrolyte imbalance. Gastric contents should be discarded if residual is more than 100 mL.
Choice C reason: Measuring the pH of gastric residual every 24 hr is not necessary, as it does not reflect the effectiveness or tolerance of the feeding. The pH of gastric residual should be checked before each feeding or every 6 to 8 hr to confirm tube placement and prevent misconnection.
Choice D reason: Flushing the tube with 15 mL of water every 4 hr is a correct action, as it can prevent clogging, maintain patency, and clear the tube of formula residue. Water should also be used to flush the tube before and after each medication administration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Using liquids to clear food from the client's mouth is not a safe intervention for dysphagia. Liquids can easily enter the airway and cause aspiration, which is the inhalation of food or fluids into the lungs. Aspiration can lead to pneumonia, respiratory distress, and death.
Choice B reason: Tilting the client's head backwards to facilitate swallowing is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it opens the airway and allows food or fluids to flow into it.
Choice C reason: Adding a thickening agent to liquids is a safe and effective intervention for dysphagia. Thickened liquids are easier to swallow and control, as they move more slowly through the mouth and throat. They also reduce the risk of aspiration, as they are less likely to enter the airway.
Choice D reason: Placing the client in a semi-Fowler's position is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it lowers the head and neck and reduces the closure of the airway. A better position for dysphagia is upright or high-Fowler's, which elevates the head and neck and enhances the closure of the airway.
Correct Answer is D
Explanation
Choice A reason: Gelatin is an incomplete protein, meaning it does not contain all nine essential amino acids that the body cannot synthesize.
Choice B reason: Legumes are incomplete proteins, but they can be combined with grains, nuts, seeds, or dairy products to form complete proteins.
Choice C reason: Almonds are incomplete proteins, but they can be combined with other foods to form complete proteins.
Choice D reason: Salmon is a complete protein, meaning it contains all nine essential amino acids that the body needs.
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