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 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.
Correct Answer is B
Explanation
Choice A reason: Applying ice packs for 15 minutes every hour is not an effective intervention for managing edema following knee replacement surgery because it can impair blood circulation and delay healing. Ice packs can also cause frostbite or nerve damage if applied for too long or too frequently. Ice packs should be used only for the first 24 to 48 hours after surgery and with a cloth barrier between the skin and the ice.
Choice B reason: Elevating the affected leg above the heart level is an effective intervention for managing edema following knee replacement surgery because it can reduce swelling and pain by facilitating venous return and lymphatic drainage. Elevation can also prevent blood clots and infection by improving blood flow and oxygen delivery to the wound site.
Choice C reason: Consuming nutrition-dense foods first is not a relevant intervention for managing edema following knee replacement surgery because it does not directly affect fluid balance or wound healing. Nutrition-dense foods are those that provide high amounts of nutrients per serving, such as eggs, cheese, nuts, beans, and meat. Nutrition-dense foods are important for overall health, but not specifically for edema management.
Choice D reason: Wearing compression stockings during the day is not a recommended intervention for managing edema following knee replacement surgery because it can interfere with wound healing and increase the risk of infection. Compression stockings can also cause skin irritation, blisters, or ulcers if worn incorrectly or too tightly. Compression stockings should be avoided until the wound is fully healed and only used under medical supervision.
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