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. "Arrange to perform all nonessential tasks for the client at one time."
Grouping nonessential tasks reduces frequent disruptions, allowing the client to rest more effectively, which is essential for recovery.
B. "Encourage the client to sleep as much as possible during the day."
Excessive daytime sleeping can disrupt the client’s sleep-wake cycle, leading to difficulty sleeping at night.
C. "Perform routine hygiene for the client during the night."
Performing hygiene tasks at night can disturb the client’s rest and impact recovery.
D. "Remove limits on visiting hours for the client." Unrestricted visiting hours can increase noise and interruptions, making it harder for the client to get adequate rest.
Correct Answer is ["A","B","C"]
Explanation
A. Positive Trousseau's sign: A positive Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff) is a classic indicator of hypocalcemia due to increased neuromuscular excitability.
B. Muscle cramps: Hypocalcemia leads to increased nerve excitability, causing muscle cramps, spasms, and tetany.
C. Tingling sensation around the lips: This is a common early sign of hypocalcemia, known as perioral paresthesia, due to increased nerve excitability.
D. Negative Chvostek's sign: A client with hypocalcemia would have a positive Chvostek’s sign, which is facial twitching when the facial nerve is tapped.
E. Abdominal distention: Hypocalcemia is more associated with diarrhea and hyperactive bowel sounds, not abdominal distention, which is more typical of hypokalemia.
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