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: 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.
Correct Answer is D
Explanation
Choice A reason: Using a washcloth to clean the denture surfaces is not a good practice for denture care because it can damage or scratch the dentures. A washcloth is too rough and abrasive for denture cleaning. A soft-bristled toothbrush or a special denture brush should be used to clean the denture surfaces gently.
Choice B reason: Wiping dentures before storing them in a dry container at night is not a good practice for denture care because it can cause warping or cracking of the dentures. Dentures should be rinsed thoroughly and soaked in water or a denture cleanser solution at night to keep them moist and prevent deformation.
Choice C reason: Flossing dentures as part of daily cleaning is not a necessary practice for denture care because it does not remove plaque or food particles effectively from the dentures. Flossing dentures can also damage or dislodge the artificial teeth or gums. Brushing and rinsing dentures are sufficient for daily cleaning.
Choice D reason: Wrapping gloved fingers with gauze to remove dentures is a good practice for denture care because it can prevent slipping or dropping of the dentures. Gauze provides friction and grip for removing dentures safely and gently. Gloves protect from contamination and infection.
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