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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A pump is usually needed to administer intermittent tube feedings, as it can control the flow rate and volume of the formula. A pump can also prevent overfeeding, aspiration, or diarrhea.
Choice B reason: Administering feedings over 10 to 20 minutes is too fast, as it can cause abdominal cramps, nausea, vomiting, or dumping syndrome. Intermittent tube feedings should be administered over 30 to 60 minutes.
Choice C reason: Administering feedings while sleeping at night is not recommended, as it can increase the risk of aspiration, reflux, or infection. Intermittent tube feedings should be administered during waking hours and with the head of the bed elevated at least 30 degrees.
Choice D reason: Advancing the rate of feedings slowly is advisable, as it can help the body adjust to the formula and prevent intolerance or complications. The rate should be increased gradually until the desired goal is reached.
Correct Answer is C
Explanation
Choice Areason: Graham crackers are made from wheat flour, which contains gluten. Peanut butter is a good source of fat and protein, but it may also contain traces of gluten from cross-contamination.
Choice Breason: Poached eggs are a good source of protein, but wheat bagel contains gluten, which is a protein found in wheat, barley, and rye. Gluten can damage the small intestine and cause malabsorption, diarrhea, and abdominal pain in people with celiac disease.
Choice C reason: Rice cereal is gluten-free and a good source of carbohydrates. Sliced bananas are gluten-free and a good source of potassium, fiber, and vitamin C.
Choice D reason: Rye toast contains gluten, which can harm people with celiac disease. Herbal tea is gluten-free and can help with hydration, but it does not provide enough calories or nutrients.
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