A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

The correct answer is A, B, C, and D.

Choice A reason: Flushing the gastrostomy tube with water is essential to maintain tube patency and prevent medication interactions. It should be done before and after medication administration. The typical amount of water used for flushing can range from 15 to 30 mL.

Choice B reason: Administering each medication separately is a critical practice to prevent drug interactions and ensure that the full dose of each medication is delivered. It also helps in preventing the clogging of the tube.

Choice C reason: Documenting all liquid volumes, including medications and water used for flushing, is important for accurate fluid intake records. This helps in maintaining fluid balance and monitoring the patient’s hydration status.

Choice D reason: Checking gastric residual volume is important to assess the patient’s tolerance to enteral feeding and to prevent complications such as aspiration. Normal gastric residual volumes are generally considered to be less than 250 mL.

Choice E reason: Using a plunger to administer medications through a gastrostomy tube is not always recommended. Medications should be administered slowly to prevent discomfort or harm, and the use of a plunger is not a standard practice across all healthcare settings.

Choice A: Remove the catheter and palpate the client’s bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.

Choice B: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.

Choice C: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.

Choice D: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.