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. "Your family member has the right to refuse care." Every competent adult has the legal and ethical right to make decisions about their own medical treatment, including the right to refuse care, even if it results in death.
B. "To continue treatment, you must be appointed as your family member's health care surrogate." The client is still competent and capable of making their own decisions, so a surrogate is not necessary or legally allowed to override their wishes.
C. "We should discuss different treatment options when your family member is not present." Discussing medical decisions behind the client’s back would be unethical and violate the principle of autonomy.
D. "I can submit your request to the ethics committee." There is no ethical dilemma here, as the client has the right to refuse treatment, and their decision must be respected.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
- Oxygen Saturation (90%) – This is a drop from the initial 95% and indicates potential hypoxia. The increased respiratory rate and depth may be compensatory mechanisms.
- Behavioral Findings ("I feel like something is wrong.") – Clients experiencing early signs of deterioration often report a sense of unease. This, combined with agitation, could indicate worsening hypovolemia or hypoxia.
The client's low hemoglobin (8.3 g/dL) and hematocrit (32%) suggest significant blood loss during surgery, which could contribute to hypoxia and hemodynamic instability. Immediate follow-up is needed to assess for potential ongoing bleeding, oxygenation issues, or early signs of shock.
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