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?

Check the pH level of the client's gastric contents.

Check the patency of the client's tube every 8 hr.

Place the client in a supine position.

Flush the client's tube with 5 mL of water.

Answer and Explanation

The Correct Answer is A

A. Check the pH level of the client's gastric contents: To verify that the tip of the gastrostomy tube is still in the stomach, the nurse should aspirate a small amount of gastric contents and test the pH. Gastric secretions are typically acidic (pH of 5 or less), whereas intestinal or respiratory secretions usually have a higher pH. This ensures the formula is delivered into the stomach and reduces the risk of aspiration.

B. Check the patency of the client's tube every 8 hr: For intermittent feedings, patency should be checked immediately before each feeding rather than on a set hourly schedule. For continuous feedings, patency and residual volumes are usually checked every 4 to 6 hours.

C. Place the client in a supine position: This is contraindicated. To prevent aspiration, the client should be placed in a semi-Fowler's or high-Fowler's position (head of the bed elevated at least 30° to 45°) during the feeding and for 30 to 60 minutes afterward.

D. Flush the client's tube with 5 mL of water: While flushing is necessary to maintain patency, 5 mL is insufficient. The standard practice is to flush with 30 mL of water before and after each intermittent feeding and whenever the feeding is interrupted.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. The client leans to the left side while sitting: While leaning to one side may indicate weakness or impaired balance, it is not as immediately concerning as the risk of aspiration. Addressing issues related to positioning and balance is important but may not pose an immediate threat to the client's safety.

B. The client coughs frequently while eating.

Coughing frequently while eating can indicate a risk of aspiration, which is a serious concern in stroke patients with left-sided weakness. Aspiration can lead to pneumonia and other respiratory complications. Therefore, it is crucial for the nurse to address this finding promptly to prevent potential respiratory compromise.

C. The client is consuming 25% of their meals: Poor oral intake and difficulty eating are concerning but do not pose an immediate threat to the client's safety compared to the risk of aspiration. However, addressing inadequate nutrition and hydration is essential for the client's overall health and recovery.

D. The client's blood pressure is 142/94 mm Hg: While monitoring blood pressure is important, especially in stroke patients who may have hypertension, the blood pressure reading provided does not indicate a hypertensive crisis or immediate risk to the client's safety. Therefore, it is not the priority finding compared to the risk of aspiration.

A. The client adjusts the head of their bed to 90°, B. The client drinks their thickened juice with a straw. C. The client tucks their chin when they swallow. D. The client takes frequent breaks while eating.

Correct Answer is B

Explanation

A. The client adjusts the head of their bed to 90°: Adjusting the head of the bed to 90° is a correct action for clients with dysphagia as it helps facilitate swallowing by promoting an upright position, reducing the risk of aspiration.

B. The client drinks their thickened juice with a straw.

Drinking thickened liquids with a straw is not recommended for clients with dysphagia. Straws can increase the risk of aspiration, as they bypass the natural protection mechanisms in the mouth and throat that help prevent liquids from entering the airway. Therefore, the nurse should intervene and provide the client with an appropriate drinking cup instead of a straw when consuming thickened liquids.

C. The client tucks their chin when they swallow: Tucking the chin when swallowing is a recommended technique for clients with dysphagia, as it helps close off the airway and directs the food or liquid toward the esophagus, reducing the risk of aspiration.

D. The client takes frequent breaks while eating: Taking frequent breaks while eating is a beneficial strategy for clients with dysphagia, as it allows them to rest and swallow safely without feeling rushed or overwhelmed by large amounts of food or liquid.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Correct Answer is B

Explanation

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

Correct Answer is B

Explanation

A nurse is caring for a client who is immobile. Which of the following interventions should the nurse plan to take to prevent plantar flexion contractures?

A nurse is preparing to administer several medications via an NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?

A nurse is caring for a client who had a stroke and coughs frequently when swallowing. The nurse should identify that which of following members of the interdisciplinary team?

A nurse is planning to administer insulin to a client who has type 1 diabetes mellitus, what action should the nurse perform first?

A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "I want to die now that my partner is gone." Which of the following responses should the nurse make?

A nurse is caring for a client who reports frequent headaches and believes balance is achieved through the concept of yin and yang. Which of the following foods should the nurse expect the client to choose to treat their headache?

A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?

A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?