A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

Measure the client's gastric residual every 12 hr.

Keep the client's head elevated at 15° during feedings.

Obtain the client's electrolyte levels every 4 hr.

Flush the client's tube with 30 mL of water every 4 hr.

Answer and Explanation

The Correct Answer is D

A) Measure the client's gastric residual every 12 hr: While monitoring gastric residual volume is important to prevent complications such as aspiration or gastric distention, it is typically done prior to each intermittent feeding, not every 12 hours for clients receiving continuous enteral feedings. Continuous feeding does not necessitate less frequent monitoring of gastric residuals.

B) Keep the client's head elevated at 15° during feedings: Elevating the client's head during feedings helps reduce the risk of aspiration. However, this action is not specific to initiating continuous enteral feedings and should be maintained throughout the client's enteral feeding regimen.

C) Obtain the client's electrolyte levels every 4 hr: Monitoring electrolyte levels every 4 hours is not necessary as part of routine care for a client initiating continuous enteral feedings. While electrolyte levels may be monitored periodically, the frequency would depend on the client's clinical condition and the healthcare provider's orders.

D) Flush the client's tube with 30 mL of water every 4 hr: Flushing the client's tube with water helps maintain patency and prevent clogging, which is especially important for clients receiving continuous enteral feedings. This action helps ensure that the tube remains clear and functional, allowing for uninterrupted delivery of the enteral feeding solution.

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Correct Answer is B

Explanation

A) Blueberry muffins are not typically recommended for a client with cholecystitis. They are likely to be high in fat, which can exacerbate symptoms such as pain and discomfort associated with cholecystitis. Foods high in fat can trigger gallbladder contractions, leading to pain and potentially worsening the condition.

B) Graham crackers are a suitable option for a client with cholecystitis. They are low in fat and gentle on the digestive system, making them less likely to exacerbate symptoms. Foods that are low in fat and easy to digest are often recommended for individuals with cholecystitis to minimize discomfort and reduce the risk of triggering symptoms.

C) 2% milk is not typically recommended for a client with cholecystitis. Dairy products, especially those with higher fat content like 2% milk, can stimulate gallbladder contractions and worsen symptoms in individuals with cholecystitis. Therefore, it is usually advised to opt for lower-fat or non-dairy alternatives.

D) Ground beef is not typically recommended for a client with cholecystitis. Beef is high in fat, which can exacerbate symptoms and trigger gallbladder contractions. Clients with cholecystitis are often advised to avoid or limit high-fat foods to reduce the risk of discomfort and complications.

A. "I have included fortified milk, fatty fish, and cheese into my diet each day." B. "I increased my intake of orange juice, lean meats, and egg whites." C. "I have been taking 500 micrograms per day of vitamin A supplement." D. "I take an 800-milligram calcium supplement with my breakfast every day."

Correct Answer is A

Explanation

A) The client's statement indicates an understanding of the teaching about improving bone health. Fortified milk, fatty fish, and cheese are all good dietary sources of calcium and vitamin D, which are essential nutrients for bone health. Incorporating these foods into the daily diet can help promote bone strength and reduce the risk of osteoporosis.

B) While orange juice contains vitamin C, which is important for collagen synthesis in bones, lean meats and egg whites do not provide significant amounts of calcium or vitamin D, which are essential for bone health. This statement does not reflect a comprehensive understanding of the dietary recommendations for improving bone health.

C) Vitamin A supplementation is not typically recommended for improving bone health, as excessive intake of vitamin A can actually be detrimental to bone health and increase the risk of fractures. This statement does not demonstrate an understanding of the appropriate dietary strategies for promoting bone health.

D) While calcium supplementation is important for bone health, taking a calcium supplement alone may not be sufficient for optimal bone health. Adequate intake of vitamin D, as well as other nutrients like magnesium and vitamin K, is also important for bone health. Additionally, the statement does not address dietary sources of calcium and vitamin D, which are preferable to supplementation when possible. Therefore, this statement does not fully demonstrate an understanding of the teaching about improving bone health.

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A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?

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