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 D
Explanation
Choice A reason: Skim milk is not an appropriate snack choice for a 9-month-old infant. Infants under 12 months of age should not consume cow's milk, as it can cause iron deficiency, gastrointestinal bleeding, and allergic reactions. Infants should be breastfed or formula-fed until they are 12 months old.
Choice B reason: Unsalted popcorn is not an appropriate snack choice for a 9-month-old infant. Popcorn is a choking hazard for infants, as it can easily get stuck in their throat or lungs. Infants should not be given any hard, round, or sticky foods that can cause choking.
Choice C reason: Raw carrots are not an appropriate snack choice for a 9-month-old infant. Raw carrots are also a choking hazard for infants, as they are hard and difficult to chew and swallow. Infants should be given soft, cooked, or pureed vegetables that can be easily mashed with their gums.
Choice D reason: Graham crackers are an appropriate snack choice for a 9-month-old infant. Graham crackers are soft, easy to chew and swallow, and provide carbohydrates and energy. They can also help infants practice their self-feeding skills and finger coordination.
Correct Answer is D
Explanation
Choice A reason: The client's creatinine level of 1.0 mg/dL is within the normal range (0.6-1.2), but it does not indicate the effectiveness of the treatment for benign prostatic hyperplasia. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. High creatinine levels can indicate kidney damage or impaired renal function.
Choice B reason: The client's urine output of 35 mL/hr is below the normal range (40-60), and it indicates the need for further assessment. Low urine output can indicate dehydration, urinary retention, or kidney failure.
Choice C reason: The client's stool consistency and color are not related to the treatment for benign prostatic hyperplasia. Soft, brown stool is normal and does not indicate any problem with the digestive system.
Choice D reason: The client's ability to urinate without straining indicates that the treatment for benign prostatic hyperplasia has been effective. Benign prostatic hyperplasia is a condition in which the prostate gland enlarges and compresses the urethra, causing difficulty in urination. Treatment options include medication, surgery, or minimally invasive procedures to reduce the size of the prostate and relieve urinary obstruction.
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