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. Blood glucose 150 mg/dL:
This blood glucose level is slightly elevated but not significantly concerning on its own. It may be related to stress or other factors. In the context of acute gastroenteritis, it might be secondary to dehydration, but it is not an immediate priority unless the client is diabetic.
B. Potassium 2.5 mEq/L:
This is the correct answer. Low potassium levels (hypokalemia) are a severe concern, especially in the context of acute gastroenteritis where there can be significant losses through vomiting and diarrhea. Hypokalemia can lead to cardiac arrhythmias and needs urgent correction.
C. Weight loss of 3% of total body weight:
While weight loss is an important parameter, a 3% weight loss is usually not an immediate concern. In cases of acute gastroenteritis, rapid weight loss might indicate severe dehydration, but this choice is not as urgent as addressing a severe electrolyte imbalance like hypokalemia.
D. Urine specific gravity 1.035:
This specific gravity indicates concentrated urine, which could be due to dehydration. While this finding is important and indicates the need for rehydration, it is not as urgent as correcting a critically low potassium level.
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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