A nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?
Elevate the head of the bed.
Measure stomach contents.
Return gastric content into the gastrostomy tube.
Flush the tube with water
The Correct Answer is A
Elevating the head of the bed to a semi-Fowler's or high Fowler's position helps prevent aspiration during the feeding. This position facilitates proper digestion and reduces the risk of
regurgitation or reflux. It allows gravity to assist in keeping the feeding in the stomach and reduces the likelihood of complications.
The other actions mentioned are also important steps in the process but should be performed after elevating the head of the bed:
Measure stomach contents: This step is usually done before administering any enteral feeding to check for the presence of residual gastric contents. It helps determine if the client is tolerating previous feedings and guides adjustments in the feeding volume or rate if needed.
Return gastric content into the gastrostomy tube: If there is a significant amount of gastric residual, it is recommended to return the contents into the stomach before administering the feeding. This helps ensure that the client receives the full prescribed amount of the enteral feeding.
Flush the tube with water: Flushing the gastrostomy tube with water before and after the feeding helps maintain tube patency, clears any residual feeding or medication, and prevents clogging.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement is incorrect and requires correction because it suggests starting the flow of urine before positioning the collection container, which can result in contamination of the specimen. The correct procedure for collecting a midstream urine specimen involves the following steps:
1. Provide the client with a clean urine specimen container.
2. Instruct the client to cleanse the genital area using a provided towelette or antiseptic wipes, wiping from front to back.
3. Instruct the client to start urinating into the toilet or bedpan.
4. As the urine stream continues, the client should pass the collection container into the stream to collect the midstream specimen.
5. Once an adequate amount of urine has been collected (as per the laboratory's instructions), the client should remove the container from the stream of urine. 6. The client can then complete urinating into the toilet or bedpan.
The other statements made by the newly licensed nurse are correct:
"Use the provided towelette to cleanse the area by moving in a back-and-forth motion": This statement correctly instructs the client to cleanse the genital area before collecting the urine specimen.
"It will be easier to use your nondominant hand to spread the labia": This statement is correct as it suggests using the nondominant hand to facilitate the collection process.
"Remove the specimen container before stopping the stream of urine": This statement is correct as it indicates that the container should be removed before completing urination.
Correct Answer is C
Explanation
The left Sims' position (also known as the left lateral position) is the appropriate position for administering a soapsuds enema. This position allows for better visualization and access to the rectum and facilitates the flow of the enema solution.
The other options mentioned are incorrect:
Inserting the tubing about 15 cm (6 in) into the anus: The specific depth of insertion may vary depending on the client, but the general guideline is to insert the tubing about 3 to 4 inches into the rectum for an adult. 15 cm (6 in) would be excessively deep and could cause discomfort or injury.
Hanging the enema container 61 cm (24 in) above the anus: The height at which the enema container is hung should be no more than 18-24 inches (45-60 cm) above the anus. Hanging it too high can cause excessive pressure and discomfort during the administration.
Putting on sterile gloves: Sterile gloves are not typically required for the administration of a soapsuds enema. Clean gloves or non-sterile gloves are generally sufficient for this procedure.
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