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","C","E","F"]

Explanation

A. History of diabetes mellitus: This is correct. Diabetes mellitus can lead to delayed wound healing due to various factors, including impaired circulation, neuropathy, and compromised immune function.

B. Cholesterol level: While abnormal cholesterol levels can impact cardiovascular health, they are not directly linked to delayed wound healing unless they are part of a broader metabolic disorder or condition that affects vascular health.

C. Prealbumin level: Prealbumin is a marker of nutritional status. Low prealbumin levels can indicate malnutrition, which is a risk factor for delayed wound healing.

D. History of hyperlipidemia: Hyperlipidemia refers to high levels of fats (lipids) in the blood, such as cholesterol and triglycerides. While hyperlipidemia is associated with cardiovascular risk, it is not a direct risk factor for delayed wound healing unless it is part of a broader metabolic syndrome or condition affecting vascular health.

E. Mini Nutritional Assessment screening tool score: This is correct. The Mini Nutritional Assessment (MNA) screening tool assesses nutritional status, and a low score indicates malnutrition or nutritional deficiencies, which can contribute to delayed wound healing.

F. History of malnutrition: This is correct. Malnutrition, whether due to inadequate intake, absorption issues, or other factors, is a significant risk factor for delayed wound healing as it affects the body's ability to repair tissues and fight infection.

A. Supine in low-Fowler's position B. Side-lying with the right side of the chest elevated C. Prone with pillows under the lower extremities D. Right lateral in Trendelenburg position

Correct Answer is D

Explanation

A. Supine in low-Fowler's position:Low-Fowler's position does not effectively promote postural drainage for left lower-lobe atelectasis. This position would not use gravity to facilitate mucus drainage or improve ventilation to the affected lobe.

B. Side-lying with the right side of the chest elevated:While side-lying positions can be useful for postural drainage, lying with the right side elevated does not optimize drainage from the left lower lobe.

C. Prone with pillows under the lower extremities:Although the prone position can help improve oxygenation in some respiratory conditions, it is not ideal for targeting left lower-lobe atelectasis in postural drainage therapy.

D. Right lateral in Trendelenburg position:In this position, the left lower lobe is elevated, allowing gravity to assist in draining secretions toward the larger airways for clearance. The Trendelenburg position further enhances the effect of gravity on secretion drainage from the lower lobe.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","E","F"]

Explanation

A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?

Correct Answer is D

Explanation

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