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 D

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

Checking the pH level of gastric contents is not typically necessary before administering intermittent tube feeding. pH testing of gastric contents is more commonly performed for clients with nasogastric tubes to confirm tube placement within the stomach. It is not routinely done before administering tube feeding through a percutaneous gastrostomy tube.

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

While it is essential to check the patency of the tube regularly, every 8 hours may not be frequent enough, especially for clients receiving intermittent tube feedings. Tube patency should be checked before and after each feeding or medication administration to ensure proper function and prevent complications.

C. Place the client in a supine position:

Placing the client in a supine position is not specifically indicated for administering intermittent tube feedings. The client's position during tube feeding administration depends on individual factors such as comfort, mobility, and risk of aspiration. The nurse should position the client in a semi-upright or upright position (typically at a 30-45 degree angle) to reduce the risk of aspiration.

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

Flushing the client's tube with water helps ensure its patency and removes any residual feeding solution or gastric contents, reducing the risk of clogging and infection. Flushing with 5 mL of water is a common practice to maintain tube patency and should be done before and after each feeding and medication administration.

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Correct Answer is D

Explanation

A. Administer metronidazole:

Metronidazole is an antibiotic medication used to treat bacterial infections, particularly those caused by anaerobic bacteria and certain parasites. It is not effective against viral infections like influenza. Administering metronidazole would not prevent the spread of influenza.

B. Don protective eyewear before entering the room:

Protective eyewear is typically worn when there is a risk of exposure to bodily fluids or other potentially infectious materials that could splash or splatter into the eyes. While protective eyewear is an important infection control measure in certain situations, it is not specifically indicated for preventing the spread of influenza, which primarily spreads through respiratory droplets.

C. Place the client in a negative airflow room:

Negative airflow rooms are designed to prevent airborne transmission of infectious agents by maintaining negative air pressure, which prevents contaminated air from flowing out of the room and into adjacent areas. While negative airflow rooms may be used for certain infectious diseases, such as tuberculosis, they are not typically indicated for influenza, which primarily spreads through respiratory droplets. Moreover, negative airflow rooms are often limited in availability and may not be necessary for every client with influenza.

D. Wear a mask when working within 3 feet of the client.

Influenza is primarily spread through respiratory droplets when an infected person coughs, sneezes, or talks. Wearing a mask when working within close proximity (within 3 feet) of the client helps prevent the nurse from inhaling respiratory droplets containing the influenza virus, reducing the risk of transmission. Masks act as a barrier that helps trap respiratory secretions and prevent them from reaching the nurse's mouth and nose.

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference. B. Reposition the client supine and recheck her BP. C. Recheck the client's BP in her other arm for comparison. D. Request that another nurse check the client's BP in 30 min.

Correct Answer is C

Explanation

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While using an appropriately sized cuff is crucial for accurate blood pressure measurement, the width of the cuff should be about 40% of the circumference of the upper arm, not 50%. However, adjusting the cuff size is not the most immediate action to take when faced with an elevated blood pressure reading.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary for routine blood pressure measurement in a sitting position. Moreover, repositioning the client may not significantly affect the blood pressure reading, especially if the initial reading was obtained correctly.

C. Recheck the client's BP in her other arm for comparison.

When obtaining a blood pressure reading, it's important to confirm the accuracy of the measurement, especially if the reading is elevated. Checking the blood pressure in the other arm allows for comparison and helps identify any significant differences between the arms, which could indicate arterial abnormalities or other issues. This step ensures accuracy and helps in making appropriate clinical decisions.

D. Request that another nurse check the client's BP in 30 min:

Waiting 30 minutes to recheck the blood pressure is not the most appropriate action when faced with an elevated reading. Prompt reevaluation and comparison of blood pressure readings are essential for accurate assessment and timely intervention, especially if the initial reading indicates hypertension.

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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?

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