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.
Keep the client's head elevated at 15° during feedings.
Measure the client's gastric residual every 12 hr.
Flush the client's tube with 30 mL of water every 4 hr.
The Correct Answer is D
A. Obtain the client's electrolyte levels every 4 hr. While monitoring electrolyte levels is important, obtaining them every 4 hours is excessive for a client who is stable and just starting enteral feedings. Typically, electrolyte levels are monitored based on clinical condition and provider orders.
B. Keep the client's head elevated at 15° during feedings. The client's head should be elevated at least 30 to 45 degrees during enteral feedings to reduce the risk of aspiration and improve gastric emptying. A position of only 15 degrees is insufficient for safety.
C. Measure the client's gastric residual every 12 hr. Gastric residuals should be assessed more frequently, especially in the initial stages of enteral feeding. It is typically recommended to check gastric residuals every 4 to 6 hours to ensure proper gastric emptying and tolerance to the feedings.
D. Flush the client's tube with 30 mL of water every 4 hr. Flushing the tube with water every 4 hours is a standard practice to maintain tube patency, prevent clogging, and ensure that the client receives adequate hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Recommend that the client eliminate the intake of carbonated beverages: Carbonated beverages, such as soda or sparkling water, can exacerbate diarrhea symptoms by increasing gas production and potentially causing abdominal discomfort. Eliminating carbonated beverages can help alleviate symptoms and improve the client's condition.
Instruct the client to increase consumption of beans: While beans are a good source of dietary fiber and can promote regular bowel movements in some individuals, they can also worsen diarrhea in others. Since the client is experiencing chronic diarrhea, increasing consumption of beans may not be advisable as it could contribute to loose stools and increased frequency.
Provide sugar-free candy for the client between meals: Sugar-free candies often contain artificial sweeteners like sorbitol or mannitol, which can have a laxative effect and worsen diarrhea. Offering sugar-free candy may not be helpful and can potentially exacerbate the client's symptoms.
Encourage the client to drink 4 oz of milk after each loose stool: Drinking milk after each loose stool is not recommended for clients experiencing chronic diarrhea. Milk contains lactose, and some individuals may have difficulty digesting it, leading to increased gas production and loose stools. Assessing the client's tolerance to milk and considering lactose-free alternatives, if needed, would be more appropriate.
Correct Answer is B
Explanation
Wipe dentures before storing them in a dry container at night: This is a correct instruction. Before storing dentures overnight, it is important to remove debris and rinse them with water. Wiping the dentures helps to remove any remaining residue or particles and keeps them relatively clean until the next use. Storing dentures in a dry container helps prevent the growth of microorganisms and maintains the shape of the dentures.
Wrap gloved fingers with gauze to remove dentures: This is not the recommended technique for removing dentures. Instead, it is recommended to use a denture brush or a soft-bristled toothbrush with a non-abrasive denture cleaner or mild soap to clean the dentures. The use of gauze may not provide adequate cleaning and may cause damage to the denture surface.
Use a washcloth to clean the denture surfaces: A washcloth is not the ideal tool for cleaning dentures. Instead, a denture brush or a soft-bristled toothbrush should be used. These tools are specifically designed to clean denture surfaces effectively without causing damage.
Floss dentures as part of daily cleaning: Flossing is not necessary for denture cleaning since dentures do not have natural teeth or spaces between them. However, it is important to clean all surfaces of the dentures using a denture brush or a soft-bristled toothbrush to remove plaque, debris, and stains.
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