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 B
Explanation
Choice A reason: Consume ten percent of total calories from saturated fat is not a correct instruction for the DASH diet. The DASH diet recommends limiting saturated fat intake to less than six percent of total calories, as saturated fat can raise blood cholesterol and increase the risk of heart disease.
Choice B reason: Consume foods that are high in calcium is a correct instruction for the DASH diet. The DASH diet emphasizes eating foods that are rich in calcium, such as low-fat dairy products, leafy green vegetables, and fortified cereals. Calcium helps regulate blood pressure and prevent osteoporosis.
Choice C reason: Increase intake of refined carbohydrates is not a correct instruction for the DASH diet. The DASH diet advises reducing intake of refined carbohydrates, such as white bread, white rice, and sweets. Refined carbohydrates can increase blood sugar and insulin levels and contribute to obesity and diabetes.
Choice D reason: Limit sodium intake to 3,200 milligrams per day is not a correct instruction for the DASH diet. The DASH diet recommends limiting sodium intake to less than 2,300 milligrams per day, or even lower to 1,500 milligrams per day for some people. Sodium can increase blood pressure and fluid retention and damage the kidneys and blood vessels.
Correct Answer is D
Explanation
Choice A reason: 1 cup of brown rice contains about 84 mg of potassium, which is low compared to other foods.
Choice B reason: One medium raw tomato contains about 292 mg of potassium, which is moderate compared to other foods.
Choice C reason: 1 oz of cheddar cheese contains about 28 mg of potassium, which is very low compared to other foods.
Choice D reason: One small baked potato contains about 738 mg of potassium, which is very high compared to other foods. Potassium is important for nerve and muscle function, but too much can cause irregular heartbeat, muscle weakness, and nausea.
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