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.
Flush the client's tube with 30 mL of water every 4 hr.
Keep the client's head elevated at 15° during feedings.
Obtain the client's electrolyte levels every 4 hr.
The Correct Answer is B
Choice A reason: Measuring the client's gastric residual every 12 hr is not frequent enough to monitor the feeding tolerance and prevent aspiration. The nurse should measure the gastric residual before each intermittent feeding or every 4 to 6 hr during continuous feeding¹².
Choice B reason: Flushing the client's tube with 30 mL of water every 4 hr is an appropriate action to maintain the tube patency, prevent clogging, and hydrate the client. The nurse should flush the tube before and after each medication administration, feeding, or gastric residual check¹³.
Choice C reason: Keeping the client's head elevated at 15° during feedings is not sufficient to prevent reflux and aspiration. The nurse should elevate the head of the bed at least 30° to 45° during feedings and for at least 30 min to 1 hr after feedings¹⁴.
Choice D reason: Obtaining the client's electrolyte levels every 4 hr is not necessary unless the client has signs of fluid or electrolyte imbalance, such as edema, dehydration, or abnormal vital signs. The nurse should monitor the client's weight, intake and output, and laboratory values as ordered by the provider¹⁵.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Offering the client a selection of beverages at each meal is not a good action to include in the plan, as it may reduce the client's appetite and intake of solid foods. The nurse should limit the client's fluid intake before and during meals, and encourage the client to consume high-calorie and high-protein drinks, such as milkshakes or smoothies, after meals.
Choice B reason: Informing the client that a weight gain of 2.3 kg (5 lb) per week is expected is not a good action to include in the plan, as it may cause anxiety and resistance in the client. The nurse should set realistic and individualized weight goals for the client, and monitor the client's weight and vital signs regularly. The nurse should also avoid focusing on the client's weight, and instead emphasize the client's health and well-being.
Choice C reason: Arranging for someone to remain with the client for 30 min after meals is a good action to include in the plan, as it can prevent the client from purging or exercising excessively. The nurse should provide a supportive and nonjudgmental environment for the client, and supervise the client's eating and toileting behaviors. The nurse should also educate the client and the family about the complications and treatment of anorexia nervosa.
Choice D reason: Encouraging the client to participate in developing dietary goals is a good action to include in the plan, as it can increase the client's sense of control and motivation. The nurse should collaborate with the client, the dietitian, and the mental health team to create a personalized and flexible meal plan that meets the client's nutritional and psychological needs. The nurse should also praise the client for any progress or achievement, and reinforce the client's positive coping skills.
Correct Answer is B
Explanation
Choice A reason: Decreased fat intake is not a barrier to wound healing, as long as the client meets the recommended daily intake of essential fatty acids. Fat is important for cell membrane integrity, inflammation, and immune function. However, excessive fat intake can increase the risk of obesity, diabetes, and cardiovascular disease, which can impair wound healing.
Choice B reason: Decreased vitamin C intake is a barrier to wound healing, as vitamin C is essential for collagen synthesis, wound repair, and antioxidant activity. Vitamin C deficiency can lead to impaired wound healing, increased susceptibility to infection, and scurvy. The nurse should encourage the client to consume foods rich in vitamin C, such as citrus fruits, berries, peppers, broccoli, and tomatoes.
Choice C reason: Increased protein intake is not a barrier to wound healing, but rather a facilitator of wound healing, as protein is necessary for tissue growth, repair, and maintenance. Protein deficiency can result in delayed wound healing, increased risk of infection, and loss of lean body mass. The nurse should advise the client to consume adequate amounts of high-quality protein, such as eggs, milk, cheese, meat, fish, poultry, soy, and nuts.
Choice D reason: Increased caloric intake is not a barrier to wound healing, but rather a facilitator of wound healing, as calories provide energy for wound healing processes. Caloric deficiency can lead to malnutrition, weight loss, and impaired wound healing. The nurse should ensure that the client meets their caloric needs based on their age, weight, activity level, and wound severity.
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