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 B
Explanation
Choice A reason: Weight gain of 0.45 kg (1 lb) per week is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended weight gain for this client is 0.35 to 0.5 kg (0.8 to 1 lb) per week.
Choice B reason: Intake of 200 extra calories per day is within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended caloric intake for this client is 2200 to 2900 calories per day, which is about 340 to 450 calories more than the pre-pregnancy intake.
Choice C reason: Intake of 100 extra calories per day is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended caloric intake for this client is 2200 to 2900 calories per day, which is about 340 to 450 calories more than the pre-pregnancy intake.
Choice D reason: Weight gain of 0.91 kg (2 lb) per week is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended weight gain for this client is 0.35 to 0.5 kg (0.8 to 1 lb) per week.
Correct Answer is B
Explanation
Choice A reason: Flossing dentures is not necessary, as dentures do not have spaces between the teeth where plaque and food particles can accumulate. Flossing dentures may damage the denture material or cause it to loosen.
Choice B reason: Dentures should be cleaned with a soft material to prevent scratches or damage. A washcloth is gentle enough to clean the denture surfaces without causing harm.
Choice C reason: Wiping dentures before storing them in a dry container at night is not advisable, as it may cause the dentures to crack or warp. Dentures should be soaked in water or a denture cleanser solution overnight to keep them moist and prevent them from losing their shape.
Choice D reason: Wrapping gloved fingers with gauze to remove dentures is not a standard practice. Dentures should be removed carefully by rocking them slightly to break the seal with the gums. Using gauze is unnecessary and may not be as effective or safe for the dentures or the oral tissues.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today