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 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.

A. Give the client's medications between meals. B. Assist the client into semi-Fowler's position. C. Encourage the client to use a straw to take the medication D. Administer the client's medications one at a time

Correct Answer is D

Explanation

A. Giving the client's medications between meals:

Administering medications between meals does not address the risk of aspiration associated with dysphagia. Moreover, timing of medication administration in relation to meals may vary depending on the specific medication requirements.

B. Assisting the client into semi-Fowler's position:

While positioning can play a role in facilitating swallowing, semi-Fowler's position alone may not be sufficient to address the risk of aspiration in clients with dysphagia. Moreover, simply positioning the client without considering other factors may not ensure safe medication administration.

C. Encouraging the client to use a straw to take the medication:

Using a straw might not be appropriate for clients with dysphagia as it can increase the risk of aspiration, especially if the client has difficulty controlling the flow of liquid or coordinating swallowing movements.

D. Administer the client's medications one at a time.

Dysphagia refers to difficulty in swallowing, which can increase the risk of choking or aspiration. Administering medications one at a time ensures that each pill is swallowed safely and reduces the risk of aspiration. It allows the nurse to closely monitor the client's ability to swallow each medication and intervene if necessary.

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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?

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