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 C
Explanation
Hydrochlorothiazide is a thiazide diuretic commonly used to treat hypertension and edema. One of the potential side effects of hydrochlorothiazide is hypokalemia (low potassium levels). To help counteract this effect, it is important for the client to increase their daily intake of foods high in potassium, such as bananas, oranges, spinach, avocados, and potatoes. This helps maintain adequate potassium levels in the body.
The other options mentioned are incorrect:
Take the medication on an empty stomach: Hydrochlorothiazide can be taken with or without food. It does not need to be taken on an empty stomach.
Muscle weakness is an expected adverse effect: Muscle weakness is not a common or expected adverse effect of hydrochlorothiazide. If the client experiences muscle weakness, they should notify their healthcare provider.
Take the medication at bedtime: Hydrochlorothiazide can be taken at any time of the day. There is no specific requirement to take it at bedtime. The dosing schedule should be determined based on the individual's needs and healthcare provider's instructions.
Correct Answer is A
Explanation
Elevating the head of the bed can help reduce the symptoms of GERD during sleep. By elevating the head, gravity can help prevent stomach acid from flowing back into the esophagus, reducing the occurrence of reflux.
The other statements do not demonstrate an understanding of the teaching: "I will sleep on my stomach with my head flat": Sleeping on the stomach can actually worsen the symptoms of GERD as it can increase the likelihood of stomach acid flowing back into the esophagus. It is generally recommended to sleep on the left side or back to minimize reflux.
"I will have a snack 1 hour before going to bed": Consuming a snack close to bedtime can increase the likelihood of reflux during sleep. It is generally recommended to avoid eating at least 2 to 3 hours before lying down to minimize reflux symptoms.
"I can have 6 ounces of alcohol before bed, to help me sleep": Alcohol can relax the lower esophageal sphincter (LES) and increase the risk of reflux. It is best to avoid alcohol before bedtime, especially for individuals with GERD.
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