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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Baked sweet potato is a good source of iron, which is a mineral that helps make hemoglobin, the protein in red blood cells that carries oxygen. Iron deficiency can cause anemia, weakness, fatigue, and pale skin.
Choice B reason: Cauliflower is not a good source of iron, but it is a good source of vitamin C, which can help increase iron absorption from plant sources. Cauliflower is also a good source of fiber, folate, and antioxidants.
Choice C reason: Egg white omelet is not a good source of iron, but it is a good source of protein, which can help with tissue repair and growth. Egg white omelet is also low in fat and cholesterol.
Choice D reason: Brown rice is not a good source of iron, but it is a good source of carbohydrates, which can provide energy and prevent protein breakdown. Brown rice is also a good source of fiber, B vitamins, and magnesium.
Correct Answer is A
Explanation
Choice A reason: Alternating the first breast that is offered to the baby with each feeding can help ensure equal stimulation and drainage of both breasts, and prevent engorgement, mastitis, or milk supply problems.
Choice B reason: Storing breastmilk in the refrigerator up to 48 hours is not recommended, as it can reduce the quality and quantity of antibodies and nutrients in the milk. The optimal storage time for breastmilk in the refrigerator is up to 24 hours.
Choice C reason: Nursing the baby once every 4 hours is not sufficient, as it can lead to insufficient milk intake, dehydration, weight loss, or jaundice in the baby. The baby should be nursed on demand, or at least every 2 to 3 hours during the day and every 4 hours at night.
Choice D reason: Offering the baby water between feedings is not necessary, as it can interfere with breastfeeding and cause water intoxication or electrolyte imbalance in the baby. Breastmilk provides enough hydration and nutrition for the baby.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today