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.
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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Related Questions
Correct Answer is C
Explanation
A. Reposition the client every 4 hours:
While repositioning is essential for preventing pressure injuries, the recommended frequency for repositioning depends on the individual client's condition, risk factors, and facility protocols. Four-hour intervals may not be sufficient for some clients, especially those at higher risk, and more frequent repositioning may be necessary.
B. Raise the head of the client's bed to a 60° angle:
Raising the head of the bed to a 60° angle may help with positioning for comfort and respiratory support but does not directly address the prevention of pressure injuries. In fact, maintaining the head of the bed elevated at such a high angle for prolonged periods could potentially increase pressure on the sacrum and increase the risk of pressure injuries in other areas.
C. Ensure the client's heels are not touching the mattress.
Keeping the client's heels off the mattress helps to alleviate pressure on this vulnerable area, reducing the risk of pressure injuries. Pressure injuries commonly occur over bony prominences when pressure is exerted on the skin over an extended period, leading to tissue damage. The heels are particularly susceptible due to the limited tissue padding and continuous pressure when lying in bed. Elevating the heels with appropriate support, such as foam pads or pillows, helps to redistribute pressure and minimize the risk of pressure injuries.
D. Massage the client's bony prominences:
Massaging bony prominences is contraindicated for clients at risk of pressure injuries as it can increase friction and shear forces on the skin, leading to tissue damage. Massage should be avoided over areas prone to pressure injuries to prevent further trauma to the skin.
Correct Answer is A
Explanation
A. "I will walk three times per week."
Regular weight-bearing exercises, such as walking, are beneficial for maintaining bone density and reducing the risk of osteoporosis in older adults. Weight-bearing activities help stimulate bone formation and strengthen bones. Therefore, the client's statement about walking three times per week demonstrates an understanding of an effective measure for reducing the risk of osteoporosis.
B. "I will avoid exposure to the sun." - Exposure to sunlight is essential for vitamin D synthesis, which helps the body absorb calcium and maintain bone health. Therefore, avoiding sunlight would not be beneficial for reducing the risk of osteoporosis.
C. "I will decrease my intake of dairy products." - Dairy products are a rich source of calcium, which is crucial for bone health. Decreasing intake of dairy products may lead to inadequate calcium intake, increasing the risk of osteoporosis.
D. "I will take 250 milligrams of calcium once per day." - While calcium supplementation is important for maintaining bone health, the recommended daily intake for older adults is higher than 250 milligrams. The client's statement suggests an inadequate understanding of calcium supplementation for osteoporosis prevention.
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