A nurse is caring for a client receiving continuous enteral feedings via a gastrostomy tube. Which nursing intervention is most important to help prevent aspiration?

Discard the container of formula every 12 hours

Irrigate the tube with sterile water before administering medications

Measure & record the residual volume after each feeding

Keep head of bed elevated 30 degrees

Answer and Explanation

The Correct Answer is D

A. Discard the container of formula every 12 hours: While this is important for preventing contamination, it does not directly address the risk of aspiration.
B. Irrigate the tube with sterile water before administering medications: This helps maintain tube patency and prevent clogging but does not significantly impact the prevention of aspiration.
C. Measure & record the residual volume after each feeding: Monitoring residuals is crucial for assessing gastric emptying and preventing overfeeding but does not directly prevent aspiration.
D. Keep head of bed elevated 30 degrees: This is the correct choice. Elevating the head of the bed reduces the risk of aspiration by ensuring that gravity helps keep the feeding in the stomach and minimizes the risk of reflux into the esophagus.

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Correct Answer is B

Explanation

A. Hypernatremia: This condition involves elevated sodium levels, which is not directly addressed by the insulin and dextrose order.
B. Hyperglycemia: While dextrose can exacerbate hyperglycemia, the order of insulin and dextrose is not for managing hyperglycemia but for another purpose.
C. Hypercalcemia: This condition involves elevated calcium levels and is not related to the use of insulin and dextrose.
D. Hyperkalemia: The administration of regular insulin with dextrose is often used to manage hyperkalemia. Insulin helps shift potassium into cells, while dextrose prevents hypoglycemia resulting from the insulin.

A. Infiltration B. Phlebitis C. Extravasation D. Infection E. - E. Limited ambulation

Correct Answer is B

Explanation

A. Infiltration: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue, typically causing swelling and coolness, but not usually a cord-like vein or a reddened streak.
B. Phlebitis: This is the correct choice. Phlebitis is inflammation of the vein, evidenced by tenderness, burning, swelling, and a reddened streak along the vein. The cord-like vein indicates inflammation.
C. Extravasation: Extravasation involves the leakage of vesicant drugs into surrounding tissue, which can cause severe tissue damage, but usually involves more than just a cord-like vein and reddened streak.
D. Infection: Infection typically presents with more systemic signs like fever and could involve purulent discharge, which is not described in this scenario.

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A nurse is caring for a client receiving continuous enteral feedings via a gastrostomy tube. Which nursing intervention is most important to help prevent aspiration?

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Naxlex Comprehensive Predictor Exams

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Explanation

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