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?
Obtain the client's electrolyte levels every 4 hr.
Measure the client's gastric residual every 12 hr.
Keep the client's head elevated at 15 during feedings.
Flush the client's tube with 30 mL of water every 4 hr.
The Correct Answer is B
Choice A rationale:
Obtaining the client's electrolyte levels every 4 hours is not standard practice when initiating continuous enteral feedings via a gastrostomy tube. While monitoring electrolytes is important, it's not done at such a high frequency unless there's a specific indication or concern.
Choice B rationale:
Measuring the client's gastric residual every 12 hours is a crucial action when initiating continuous enteral feedings. Gastric residual volume helps to assess the client's tolerance to the feeding, the rate of digestion and absorption, and the risk of aspiration. If the residual volume is too high, it could indicate feeding intolerance or delayed gastric emptying.
Choice C rationale:
Keeping the client's head elevated at 15 degrees during feedings is not standard practice for continuous enteral feedings. This angle could potentially promote reflux and increase the risk of aspiration. Instead, the head of the bed is usually elevated at least 30 degrees to help prevent reflux and aspiration.
Choice D rationale:
Flushing the client's tube with 30 mL of water every 4 hours is not a standard practice for continuous enteral feedings. Flushing the tube helps maintain its patency, but it's usually done before and after medication administration or as needed to prevent clogs, not on such a frequent schedule.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Using a washcloth to clean denture surfaces is not the recommended method as it can lead to scratches on the dentures, making them more susceptible to bacterial growth and staining.
Choice B rationale:
Wiping dentures before storing them in a dry container at night is the correct choice. This practice helps remove debris and bacteria, preventing them from accumulating overnight. Storing dentures in a dry container helps maintain their shape and prevents the growth of microorganisms that thrive in moist environments.
Choice C rationale:
Flossing dentures is not necessary and may damage or distort them. Unlike natural teeth, dentures do not have interdental spaces that require flossing.
Choice D rationale:
Wrapping gloved fingers with gauze to remove dentures is not the best practice, as it may cause damage to the dentures and also increases the risk of contamination.
Correct Answer is B
Explanation
Choice A rationale:
A rate of 0.45 kg (1 lb)/day is an extremely rapid weight loss rate that is not realistic or safe for most individuals. Such a rapid weight loss could lead to muscle loss, nutrient deficiencies, and other health complications.
Choice B rationale:
This choice is the correct answer. A weight loss rate of 0.45 kg (1 lb)/week is generally considered a safe and sustainable rate. This gradual weight loss allows the body to adjust and minimize the risk of adverse effects commonly associated with rapid weight loss.
Choice C rationale:
A weight loss rate of 0.23 kg (0.5 lb)/week is even slower than the recommended rate in choice B. While it might be very cautious, it might not provide the client with the desired progress in a reasonable timeframe.
Choice D rationale:
A rate of 0.23 kg (0.5 lb)/day is another unrealistic and rapid weight loss rate. It's not a sustainable approach and could lead to various health issues.
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