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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
A. "I will expect a warm feeling when the dye is injected."
This statement is incorrect. Barium swallow involves swallowing a contrast medium, not an injection. The warm feeling might be associated with injected substances but not with a barium swallow.
B. "I will drink plenty of fluids after the test."
This statement is correct. After a barium swallow, it's important to drink plenty of fluids to help clear the barium from the body and prevent constipation.
C. "I will maintain a clear liquid diet 24 hours before the test."
This statement is incorrect. A clear liquid diet might be recommended before certain medical procedures, but for a barium swallow, often patients are asked to avoid eating or drinking for a 8hours before the test.
D. "I will expect my stool to be black after this procedure."
Barium can cause stools to appear white or light-colored for several days after the procedure.Black stools could indicate the presence of gastrointestinal bleeding or other issues unrelated to the barium swallow.
Correct Answer is B
Explanation
A. Prior to percussing the abdomen:
Before percussing, the nurse should listen to bowel sounds. Percussion, a technique used to assess the density of underlying structures, can create vibrations that might interfere with accurate bowel sound assessment.
B. Prior to inspecting the abdomen:
Inspecting the abdomen involves visually assessing the abdominal area for any signs of distension, lesions, or abnormal movements. Bowel sounds are auscultated prior to inspection to avoid stimulating the bowels, which might affect the accuracy of the assessment.
C. After checking for kidney tenderness:
Checking for kidney tenderness, often done by gently percussing the costovertebral angle (CVA), is a separate assessment and does not interfere with bowel sound auscultation. However, bowel sounds are usually assessed before performing any other abdominal assessments to get the most accurate baseline data.
D. After palpating the abdomen:
Palpation involves gently pressing different areas of the abdomen to assess for tenderness, masses, or organ enlargement. Similar to inspection and percussion, palpation can stimulate bowel sounds, so it's essential to auscultate bowel sounds before palpating the abdomen to avoid any interference.
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