The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding?

Measure vital signs.

Lower the head of the bed.

Verify tube patency.

Assist the client to a prone position.

Answer and Explanation

The Correct Answer is C

C. Before administering a feeding through a gastrostomy tube, it is essential to verify that the tube is patent (open and unobstructed). Tube patency ensures that the feeding formula or medication can flow freely into the stomach or intestines without encountering any blockages or resistance. The nurse should flush the tube with water to check for patency and ensure proper functioning before initiating the feeding.

A. Vital signs are typically assessed for overall health monitoring and to detect any immediate changes in the client's condition. However, they are not specifically required before every feeding via gastrostomy tube unless there are specific concerns about the client's stability.

B. This option is not typically necessary before administering a feeding through a gastrostomy tube. In fact, elevating the head of the bed to at least 30 to 45 degrees is often recommended during and after feeding to minimize the risk of aspiration. This position helps to promote digestion and reduce the likelihood of reflux or regurgitation of the feeding.

D. Assisting the client to a prone (face-down) position is unnecessary and potentially unsafe before administering a feeding through a gastrostomy tube. The recommended position for feeding via gastrostomy tube is typically semi-Fowler's position (elevated head of the bed), which helps prevent aspiration and facilitates digestion.

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

Explanation

A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.

E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.

B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.

C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.

D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.

A. interventions. B. expected outcomes. C. definitions. D. diagnoses.

Correct Answer is B

Explanation

B. Expected outcomes are specific, measurable criteria used to determine goal achievement. These outcomes are set during the planning phase of the nursing process in collaboration with the client. During evaluation, the nurse compares the client's actual progress with these expected outcomes. This assessment helps determine whether the goals were met, partially met, or not met, which guides further nursing actions.

A. During the evaluation phase, the nurse assesses the effectiveness of these interventions in achieving the desired outcomes rather than the interventions themselves. The focus is on determining whether the interventions were appropriate, timely, and effective in meeting the client's goals.

C Definitions typically refer to the meaning or understanding of terms used in the nursing process, such as nursing diagnoses or medical conditions. They provide clarity and context to ensure accurate assessment, planning, and intervention. However, definitions themselves are not directly evaluated in the evaluation phase of the nursing process.

D. In the evaluation phase, the nurse assesses the client's response to interventions aimed at addressing these diagnoses. The focus is on determining the effectiveness of the care provided rather than evaluating the diagnoses themselves.

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The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

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

Explanation

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Correct Answer is B

Explanation

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Joint Commission (TJC) requires that a(n)

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