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
The correct answer is: b. Offer the client frozen bananas as a snack.
Choice A: Discourage the use of a straw
Discouraging the use of a straw is not the best intervention for a client with stomatitis following radiation therapy. While using a straw might cause some discomfort, it is not a primary concern. The focus should be on providing soothing and non-irritating foods.
Choice B: Offer the client frozen bananas as a snack
Offering the client frozen bananas as a snack is an appropriate intervention. Frozen bananas can provide a soothing effect on the inflamed oral tissues and are less likely to cause irritation compared to other foods. They are also nutritious and easy to consume, making them a suitable option for clients with stomatitis.
Choice C: Serve the client hot meals
Serving hot meals is not recommended for clients with stomatitis. Hot foods can exacerbate the discomfort and irritation in the mouth, making it more painful for the client to eat. It is better to serve foods at a moderate or cool temperature to avoid further irritation.
Choice D: Avoid serving sauces or gravies
Avoiding sauces or gravies is not the best intervention for a client with stomatitis. While some sauces or gravies might be irritating, others can be soothing and help make the food easier to swallow. The key is to choose mild and non-spicy options that do not irritate the oral tissues.
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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