A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

Keep the head of the bed elevated at 15 degrees.

Place enough formula in the feeding bag to last for 8 hr of continuous feeding

Flush the tube with 30 ml of water every 4 hr.

Change the feeding bag and tubing every 72 hr.

Answer and Explanation

The Correct Answer is C

A. Keep the head of the bed elevated at 15 degrees.

This is not sufficient for preventing aspiration and ensuring proper digestion. The head of the bed should be elevated at least 30 degrees to reduce the risk of aspiration and promote better digestion of enteral feedings.

B. Place enough formula in the feeding bag to last for 8 hr of continuous feeding: It is recommended to change the feeding formula and bag every 24 hours. Placing formula for an extended period can increase the risk of bacterial growth.

C. Flush the tube with 30 ml of water every 4 hr: Regular flushing of the tube helps maintain patency, prevents clogging, and ensures proper hydration. Flushing every 4 hours is a standard practice for continuous feeding.

D. Change the feeding bag and tubing every 72 hr: Feeding bags and tubing should be changed more frequently, typically every 24 hours, to reduce the risk of infection.

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Correct Answer is ["10"]

Explanation

To calculate the number of milliliters (mL) of the hydroxyzine oral suspension to administer, you can use the following formula:

Dose (mL) = Ordered Dose (mg)/ Stock Concentration (mg/mL)

In this case:

- Ordered Dose = 50 mg

- Stock Concentration = 25 mg/5 mL

First, calculate the mg per mL from the stock concentration:

mg per mL = 25 mg/ 5 mL= 5 mg/mL

Now, use the formula to find the mL to administer:

Dose (mL) = 50 mg/ 5 mg/mL = 10 mL

So, the nurse should administer 10 mL of hydroxyzine oral suspension.

A. Check the client for a positive Chvostek's sign. B. Discontinue the TPN infusion. C. Request a potassium replacement. D. Administer glucagon IM.

Correct Answer is C

Explanation

A. Check the client for a positive Chvostek's sign.
Chvostek's sign is a clinical sign of hypocalcemia (low calcium levels), not related to the client's potassium levels. The given potassium level is low, not calcium.

B. Discontinue the TPN infusion.
While the potassium level is low, discontinuing TPN without addressing the potassium deficiency can lead to further complications. TPN can be adjusted to include potassium supplementation.

C. Request a potassium replacement.
The client's low potassium level (3.0 mEq/L) requires potassium replacement. This can be done through the TPN solution or via a separate IV infusion. This choice is correct.

D. Administer glucagon IM.
Glucagon is not used to treat low potassium levels.

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A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer hydroxyzine HCL 50 mg PO. Available is hydroxyzine oral suspension 25 mg/5 mL. How many ml. should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["10"]

Explanation

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L. sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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