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 A

Explanation

A. Thirty minutes before breakfast and the evening meal: This is the correct option. Sucralfate is typically administered 30 minutes before meals or on an empty stomach to allow it to form a protective coating over ulcers without interference from food.

B. One hour before breakfast and the evening meal: This choice is not typical for sucralfate administration. Waiting for a whole hour before meals might cause the patient to miss the window where the medication is most effective.

C. At the time the client takes an antacid: Administering sucralfate simultaneously with an antacid is not recommended because antacids can interfere with its effectiveness by neutralizing the stomach acid needed to activate sucralfate.

D. At the time the client takes a proton-pump inhibitor: Sucralfate should not be administered simultaneously with proton-pump inhibitors. Proton-pump inhibitors reduce stomach acid, which is needed to activate sucralfate.

A. To remove gastric acid that might cause dyspepsia B. To identify delayed gastric emptying C. To determine the client's electrolyte balance D. To confirm the placement of the NG tube

Correct Answer is B

Explanation

A. To remove gastric acid that might cause dyspepsia:
This statement is not accurate. Measuring gastric residuals is not done to remove gastric acid but rather to ensure that the previous feeding has been digested and moved into the intestines before the next feeding is administered.

B. To identify delayed gastric emptying:This is the correct purpose. Measuring gastric residual helps assess whether the stomach is properly emptying its contents. High residual volumes can indicate delayed gastric emptying, which can increase the risk of aspiration and other complications during enteral feeding.

C. To determine the client's electrolyte balance:
Measuring gastric residuals is not used to assess the client's overall electrolyte balance. Electrolyte balance is typically assessed through blood tests and clinical evaluations, not by checking gastric residuals.

D. To confirm the placement of the NG tube:
Although verifying NG tube placement is critical before feeding, this is typically done by checking the tube’s external length, aspirating gastric contents, and confirming placement through pH testing or an X-ray, not by measuring gastric residual.

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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 planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administered twice daily. Which of the following times should the nurse plan to administer the medication?

Correct Answer is A

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Correct Answer is B

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