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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "We can discuss what you can expect during your stay."
This statement acknowledges the client's feelings of anxiety and offers support by indicating a willingness to discuss what they can expect during their stay. Providing information about the facility's routines, procedures, and what to expect can help alleviate anxiety by giving the client a sense of control and understanding. It also opens the door for the client to ask questions and express any concerns they may have.
B. "Most people are scared their first time in a health care facility":
While this statement attempts to normalize the client's feelings by suggesting that it is common to feel scared, it may not effectively address the client's individual concerns or provide reassurance. Additionally, some clients may not find comfort in knowing that others are also scared.
C. "You have nothing to worry about. Everything will be fine":
This statement may come across as dismissive of the client's feelings and does not acknowledge or validate their anxiety. It also makes assumptions about the client's experience and may not be accurate for all clients. Providing blanket reassurances without addressing the client's specific concerns may not be effective in alleviating their anxiety.
D. "Why are you feeling scared about being in this facility?":
While it is important for the nurse to explore the client's feelings and concerns, asking a direct question like this may put pressure on the client to articulate their anxiety without offering immediate support or reassurance. It is better to provide a statement that offers support and opens the door for the client to express their concerns in their own time and comfort level.
Correct Answer is B
Explanation
A. "I will remove my antiembolic stockings while I am in bed": Antiembolic stockings, also known as compression stockings, are worn to prevent deep vein thrombosis (DVT) by promoting venous return. Removing them while in bed would compromise their effectiveness in preventing blood clots.
B. "I will perform ankle and knee exercises every hour."
Performing ankle and knee exercises every hour helps prevent complications such as muscle atrophy, contractures, and thromboembolism associated with immobility. These exercises promote circulation, maintain joint mobility, and prevent stiffness.
C. "I will hold my breath when rising from a sitting position": Holding one's breath while rising from a sitting position can increase intra-abdominal pressure and potentially cause dizziness or fainting. It is not a recommended practice and may lead to orthostatic hypotension.
D. "I will have my partner help me change positions every 4 hours": Changing positions every 4 hours is important for preventing pressure ulcers and promoting comfort, but it may not be frequent enough to prevent other adverse effects of immobility, such as joint stiffness and muscle weakness. Frequent position changes, at least every 2 hours, are recommended to maintain circulation and prevent complications.
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