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: Baked sweet potato is a good source of iron, which is a mineral that helps make hemoglobin, the protein in red blood cells that carries oxygen. Iron deficiency can cause anemia, weakness, fatigue, and pale skin.
Choice B reason: Cauliflower is not a good source of iron, but it is a good source of vitamin C, which can help increase iron absorption from plant sources. Cauliflower is also a good source of fiber, folate, and antioxidants.
Choice C reason: Egg white omelet is not a good source of iron, but it is a good source of protein, which can help with tissue repair and growth. Egg white omelet is also low in fat and cholesterol.
Choice D reason: Brown rice is not a good source of iron, but it is a good source of carbohydrates, which can provide energy and prevent protein breakdown. Brown rice is also a good source of fiber, B vitamins, and magnesium.
Correct Answer is A
Explanation
Choice A reason: Abdominal obesity is a risk factor for developing diabetes mellitus. Abdominal obesity, also known as central obesity or visceral fat, is the accumulation of fat around the abdomen and organs. Abdominal obesity can cause insulin resistance, inflammation, and metabolic syndrome, which are all associated with diabetes.
Choice B reason: Elevated HDL level is not a risk factor for developing diabetes mellitus. HDL stands for high-density lipoprotein, which is a type of cholesterol that carries excess cholesterol from the tissues to the liver for disposal. HDL is also known as "good" cholesterol, as it helps protect against heart disease and stroke. A high HDL level is desirable and beneficial for health.
Choice C reason: History of hypotension is not a risk factor for developing diabetes mellitus. Hypotension means low blood pressure, which is usually defined as less than 90/60 mm Hg. Hypotension can cause symptoms such as dizziness, fainting, fatigue, and blurred vision. Hypotension can be caused by dehydration, blood loss, medication side effects, or other conditions.
Choice D reason: History of hyperthyroidism is not a risk factor for developing diabetes mellitus. Hyperthyroidism means overactive thyroid gland, which produces too much thyroid hormone. Thyroid hormone regulates metabolism, growth, and development. Hyperthyroidism can cause symptoms such as weight loss, nervousness, palpitations, heat intolerance, and insomnia. Hyperthyroidism can be caused by Graves' disease, thyroid nodules, or thyroiditis.
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