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: Alternating the first breast that is offered to the baby with each feeding is a good practice for breastfeeding because it can ensure equal stimulation and drainage of both breasts, which can prevent engorgement, mastitis, or low milk supply. Alternating breasts can also provide the baby with both foremilk and hindmilk, which have different compositions and benefits.
Choice B reason: Storing breast milk in the refrigerator up to 48 hours is not a good practice for breastfeeding because it can reduce the quality and safety of the milk. Breast milk should be stored in the refrigerator for no longer than 24 hours or in the freezer for no longer than 6 months. Breast milk should also be stored in clean, sterile containers and labeled with the date and time of expression.
Choice C reason: Nursing the baby once every 4 hours is not a good practice for breastfeeding because it can decrease the milk production and supply, which can affect the growth and development of the baby. Breastfeeding should be done on demand or at least every 2 to 3 hours during the day and every 3 to 4 hours at night. Breastfeeding should also last for at least 10 to 15 minutes per breast or until the baby is satisfied.
Choice D reason: Offering the baby water between feedings is not a good practice for breastfeeding because it can interfere with the baby's appetite and intake of breast milk, which can cause dehydration, malnutrition, or failure to thrive. Breast milk contains enough water and nutrients to meet the baby's needs for the first six months of life. Water should be avoided or limited until the baby starts solid foods.
Correct Answer is B
Explanation
Choice A reason: 1 slice of bread is equivalent to 1 oz of grains, not protein. Bread is a good source of carbohydrates, fiber, and B vitamins, but it does not provide enough protein for a toddler.
Choice B reason: 1 scrambled egg is equivalent to 1 oz of protein. Egg is a complete protein, meaning it contains all nine essential amino acids that the body cannot make. Egg is also a good source of iron, choline, and vitamin D.
Choice C reason: 1/2 cup peas is equivalent to 1/2 oz of protein and 1/2 cup of vegetables. Peas are an incomplete protein, meaning they lack some essential amino acids. Peas are also a good source of fiber, vitamin C, and folate.
Choice D reason: 2 tbsp peanut butter is equivalent to 2 oz of protein. Peanut butter is an incomplete protein, but it can be combined with bread or crackers to form a complete protein. Peanut butter is also a good source of fat, magnesium, and niacin.
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