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. "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.

A. Place the sterile field at the level of the nurse's hips. B. Hold bottles of sterile solution with the label in the palm of the hand. C. Open the outermost flap of the sterile kit toward the body. D. Pour liquids into containers outside the sterile field

Correct Answer is B

Explanation

A.Place the sterile field at the level of the nurse’s hips: This is not a recommended action. The sterile field should be placed at waist level or slightly above to ensure easy access and prevent contamination.

B. Hold bottles of sterile solution with the label in the palm of the hand: This protects the label from becoming wet and illegible, which is proper sterile technique.

C. Open the outermost flap of the sterile kit toward the body: When opening a sterile kit or package, the nurse should open the outermost flap away from the body to prevent contamination. Opening the flap toward the body increases the risk of airborne particles or contaminants from the nurse's clothing or skin entering the sterile field.

D. Sterile liquids should be poured into sterile containers on the sterile field, taking care not to contaminate the field.

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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

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