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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: Flushing the tubing with water every 4 hours can prevent the tubing from clogging by clearing any residual formula or medication from the lumen.

Choice B reason: Replacing the bag and tubing every 24 hours can prevent bacterial contamination, but it does not prevent the tubing from clogging.

Choice C reason: Administering the feeding by gravity drip can cause overfeeding, aspiration, or diarrhea, but it does not prevent the tubing from clogging.

Choice D reason: Heating the formula prior to infusion can cause bacterial growth, nutrient loss, or burns, but it does not prevent the tubing from clogging.

A. Potassium 3.5 mEq/L B. Sodium 145 mEq/L C. Hematocrit 53% D. HbA1c 5%

Correct Answer is C

Explanation

Choice A reason: Potassium 3.5 mEq/L is not a finding that indicates fluid volume deficit because it is within the normal range, which is 3.5 to 5.0 mEq/L. Potassium is an electrolyte that regulates nerve and muscle function, acid-base balance, and fluid balance. Potassium level can be affected by various factors, such as diet, medication, kidney function, and dehydration.

Choice B reason: Sodium 145 mEq/L is not a finding that indicates fluid volume deficit because it is within the normal range, which is 136 to 145 mEq/L. Sodium is an electrolyte that regulates blood pressure, blood volume, and fluid balance. Sodium level can be affected by various factors, such as diet, medication, kidney function, and fluid loss.

Choice C reason: Hematocrit 53% is a finding that indicates fluid volume deficit because it is above the normal range, which is 38 to 50% for men and 34 to 46% for women. Hematocrit is the percentage of red blood cells in the total blood volume. Hematocrit level can increase due to dehydration, which causes hemoconcentration or increased blood viscosity.

Choice D reason: HbA1c 5% is not a finding that indicates fluid volume deficit because it is within the normal range, which is less than 5.7%. HbA1c is the percentage of hemoglobin that is attached to glucose. HbA1c level reflects the average blood glucose level over the past two to three months. HbA1c level can be affected by various factors, such as diabetes, anemia, and medication.

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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?

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