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 A

Explanation

A. Use trochanter rolls beside the client's legs.

Trochanter rolls are supportive devices placed alongside the client's hips and thighs to prevent external rotation of the hips and maintain proper alignment of the legs. They help prevent hip abduction and rotation, which can lead to hip dislocation or pressure injuries, especially in immobile clients. Therefore, using trochanter rolls is essential in the care of immobile clients to maintain proper alignment and prevent complications.

B. Place the client's arms at their side when turning them: Placing the client's arms at their side during turning may limit movement and comfort. Instead, the nurse should support the client's arms in a position that promotes comfort and maintains proper alignment.

C. Cross the client's ankles when lying supine: Crossing the client's ankles can lead to compromised circulation and pressure on the bony prominences of the ankles, increasing the risk of pressure injuries. It is not recommended to cross the client's ankles in the supine position.

D. Logroll the client every 4 hr: Logrolling is a technique used to move clients with suspected spinal cord injuries while maintaining spinal alignment. However, it is not necessary to logroll an immobile client every 4 hours unless there are specific indications, such as suspicion of a spinal injury. Frequent repositioning, including the use of trochanter rolls, is essential to prevent pressure injuries and maintain skin integrity but should be individualized based on the client's needs and condition.

A. Honey B. Fresh vegetables C. Chicken D. Chili peppers

Correct Answer is A

Explanation

A. Honey: In Traditional Chinese Medicine (TCM), yin and yang are concepts used to describe the balance between opposing forces in the body. Yin represents coolness, darkness, and calmness, while yang represents warmth, brightness, and activity. In TCM, headaches may be viewed as an imbalance between yin and yang energies.

Given this perspective, honey is considered a yin-nourishing food in TCM. It is believed to have cooling properties that can help balance excess yang energy in the body. Therefore, the client who believes in the concept of yin and yang may choose honey to treat their headache, aiming to restore balance by reducing yang energy.

B. Fresh vegetables: While fresh vegetables are generally considered healthy and nutritious, they do not have specific associations with yin or yang energies in TCM. Therefore, the client may not necessarily choose fresh vegetables to address a headache based on the yin-yang concept.

C. Chicken: Chicken is a neutral food in TCM and is not specifically associated with either yin or yang energies. Therefore, the client may not necessarily choose chicken to address a headache based on the yin-yang concept.

D. Chili peppers: Chili peppers are considered yang-warming foods in TCM due to their spicy nature. They are believed to increase yang energy in the body. Therefore, the client who believes in the concept of yin and yang may not choose chili peppers to treat their headache, as it may exacerbate yang energy rather than balance it.

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