A nurse is preparing to administer intermittent tube feeding to a client who has a percutaneous gastrostomy tube. Which of the following actions should the nurse take?
Flush the client's tube with 5 mL of water.
Place the client in a supine position.
Check the pH level of the client's gastric contents.
Check the patency of the client's tube every 8 hr.
The Correct Answer is C
A. Flush the client's tube with 5 mL of water. – This is incorrect because the standard amount of water used to flush a feeding tube is typically 30–50 mL to maintain patency and prevent clogging.
B. Place the client in a supine position. – This is incorrect because the client should be placed in a semi-Fowler’s or Fowler’s position (at least 30–45 degrees) to reduce the risk of aspiration.
C. Check the pH level of the client's gastric contents. – This is the correct answer. Checking the pH of gastric contents (typically ≤5.5) helps confirm proper tube placement before administering feedings, reducing the risk of aspiration.
D. Check the patency of the client's tube every 8 hr. – This is incorrect because tube patency should be checked before each feeding or medication administration, not just every 8 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A nurse administers the wrong medication to a client. – This is an example of negligence, as it represents a failure to follow the standard of care, potentially causing harm to the client. Nurses are expected to follow the "five rights" of medication administration to prevent errors.
B. A nurse applies wrist restraints to a client in violation of the facility's restraint use policy. – This is an example of false imprisonment, not negligence, as it involves restricting a client’s movement without proper justification.
C. A nurse touches a client in an offensive manner. – This is an example of battery, which is the intentional act of touching someone without their consent in a harmful or offensive way.
D. A nurse shares information about a client with family members without the client's consent. – This is an example of a breach of confidentiality, violating HIPAA regulations.
Correct Answer is A
Explanation
A. Translucent, red tissue Granulation tissue is red or pink due to increased blood supply and is a sign of healing.
B. Soft, yellow tissue This describes slough, which consists of dead tissue and debris that may delay wound healing.
C. Stringy, white tissue This could indicate fibrin or slough, which may require debridement.
D. Thick, black tissue This describes eschar, which is necrotic (dead) tissue and needs removal for proper wound healing.
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