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.

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Correct Answer is B

Explanation

A. "Tell me more about your partner." - While exploring the client's feelings about their partner may be relevant to understanding their current emotional state, it does not directly address the statement indicating suicidal ideation. The priority in this situation is to assess the client's risk of self-harm or suicide.

B. "Have you thought about harming yourself?"

This response directly addresses the client's statement expressing thoughts of dying and allows the nurse to assess the client's risk of self-harm or suicide. It opens up a dialogue about the client's feelings and intentions, which is crucial for ensuring their safety and providing appropriate support and intervention.

C. "You should discuss these feelings with your provider." - While encouraging the client to communicate with their healthcare provider is important, it does not address the immediate concern of potential self-harm or suicide. The nurse should assess the client's safety and provide support before encouraging further discussion with the provider.

D. "Why did you stop taking your medication?" - While medication non-adherence may contribute to worsening symptoms of depression, it is not the immediate concern in this situation. The client's statement expressing thoughts of dying requires immediate assessment of suicidal ideation and intervention to ensure their safety.

A. Administer the client's insulin dose using a tuberculin syringe. B. Use a filter needle when withdrawing medication from the multidose vial. C. Verify the dose of insulin with another nurse once it is prepared. D. Mix the client's long-acting and rapid-acting insulin dose in one syringe.

Correct Answer is C

Explanation

A. Administer the client's insulin dose using a tuberculin syringe:

While using an appropriate syringe for insulin administration is important, ensuring the accuracy of the dosage precedes the actual administration. Therefore, verifying the dose takes precedence over selecting the syringe.

B. Use a filter needle when withdrawing medication from the multidose vial:

While using a filter needle can be beneficial to prevent contamination, ensuring the correct dosage is more critical in preventing adverse effects associated with incorrect insulin administration.

C. Verify the dose of insulin with another nurse once it is prepared.

Before administering insulin to a client with type 1 diabetes, it is essential to ensure accuracy in dosage. Verifying the dose with another nurse helps minimize the risk of errors, ensuring the client receives the correct amount of insulin. This step aligns with the principle of double-checking medications for safety, especially in critical situations like insulin administration.

D. Mix the client's long-acting and rapid-acting insulin dose in one syringe:

Mixing different types of insulin in one syringe is not standard practice unless specifically instructed by a healthcare provider. This step should be performed only if explicitly ordered an

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