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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Fried chicken is an acceptable choice for a client who is taking tranylcypromine, a monoamine oxidase inhibitor (MAOI). MAOIs can cause a hypertensive crisis if the client consumes foods that are high in tyramine, such as aged cheeses, cured meats, smoked fish, and fermented products. Fried chicken does not contain tyramine and is safe to eat.
Choice B reason: Salami is not an acceptable choice for a client who is taking tranylcypromine, as it is a cured meat that is high in tyramine. The nurse should advise the client to avoid salami and other similar foods, such as pepperoni, ham, bacon, and sausage.
Choice C reason: Smoked salmon is not an acceptable choice for a client who is taking tranylcypromine, as it is a smoked fish that is high in tyramine. The nurse should advise the client to avoid smoked salmon and other similar foods, such as herring, anchovies, and caviar.
Choice D reason: Cheddar cheese is not an acceptable choice for a client who is taking tranylcypromine, as it is an aged cheese that is high in tyramine. The nurse should advise the client to avoid cheddar cheese and other similar foods, such as blue cheese, Swiss cheese, and Parmesan cheese.
Correct Answer is D
Explanation
Choice D reason: A calorie reduction of 500 fewer calories per day can result in a weight loss of about 0.45 kg (1 lb) per week, which is a safe and realistic goal for most clients. A pound of fat contains about 3,500 calories, so reducing the daily intake by 500 calories can create a deficit of 3,500 calories per week.
Choice A reason: A weight loss of 0.45 kg (1 lb) per day is too rapid and unhealthy, as it can cause dehydration, electrolyte imbalance, muscle loss, and metabolic slowdown. It can also be unsustainable and lead to weight regain. A calorie reduction of 500 fewer calories per day cannot achieve such a drastic weight loss.
Choice B reason: A weight loss of 0.23 kg (0.5 lb) per day is also too rapid and unhealthy, for the same reasons as choice A. A calorie reduction of 500 fewer calories per day cannot achieve such a drastic weight loss.
Choice C reason: A weight loss of 0.23 kg (0.5 lb) per week is too slow and unlikely, as it would require a calorie reduction of only 250 fewer calories per day. This is not enough to create a significant deficit and stimulate weight loss. A calorie reduction of 500 fewer calories per day can result in a faster weight loss.
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