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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Administer antiemetics on a schedule. Antiemetics are medications used to prevent or relieve nausea and vomiting. By administering them on a schedule, the nurse can help manage and control the client's nausea more effectively.

Providing a snack 30 minutes before treatments is not an appropriate intervention for nausea associated with radiation therapy. In fact, eating before radiation therapy may worsen nausea in some individuals. It is generally recommended to have a light meal or snack a few hours before the treatment to avoid an empty stomach but also prevent overeating that can trigger nausea.

Ensuring foods are served hot is not a recommended intervention for nausea. In fact, hot foods may exacerbate nausea in some individuals. It is advisable to serve foods at a cooler or room temperature, as cooler foods may be better tolerated.

Serving low carbohydrate meals is not specific to managing nausea associated with radiation therapy. While some individuals may find low carbohydrate meals easier to digest, there is no strong evidence suggesting that they alleviate nausea specifically. The choice of meals should be based on the client's preferences, tolerance, and any dietary restrictions they may have.

A. "I like to drink a glass of warm milk before bed to help me sleep." B. "I try to follow a low-fat, high-protein diet to help me maintain my weight." C. "I stopped drinking caffeinated beverages several weeks ago." D. "I have recently stopped drinking alcohol."

Correct Answer is A

Explanation

The nurse should identify the statement "I like to drink a glass of warm milk before bed to help me sleep" as a contributing factor to gastroesophageal reflux disease (GERD). Consuming a glass of warm milk before bed can worsen GERD symptoms due to its high-fat content. High-fat foods, including dairy products, can relax the lower esophageal sphincter (LES) and delay gastric emptying, allowing stomach acid to flow back into the esophagus, leading to symptoms of GERD.

"I try to follow a low-fat, high-protein diet to help me maintain my weight": Following a low-fat, high-protein diet is actually beneficial for managing GERD. High-fat foods can worsen GERD symptoms by relaxing the LES and delaying gastric emptying, while a low-fat diet can help reduce symptoms.

"I stopped drinking caffeinated beverages several weeks ago": Avoiding caffeinated beverages is a positive step in managing GERD. Caffeine can stimulate acid production in the stomach and relax the LES, contributing to GERD symptoms.

"I have recently stopped drinking alcohol": Stopping alcohol consumption is also beneficial for managing GERD. Alcohol can relax the LES and increase acid production in the stomach, leading to GERD symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who is receiving radiation therapy and is experiencing nausea. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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