A nurse is administering continuous enteral feedings for a client through a percutaneous esophageal gastrostomy (PEG) tube. Which of the following actions should the nurse take?
Check gastric residuals every 8 hr.
Return gastric contents if residual is less than 250 mL.
Measure the pH of gastric residual every 24 hr.
Flush the tube with 15 mL of water every 4 hr.
The Correct Answer is D
Choice A reason: Checking gastric residuals every 8 hr is not frequent enough, as it can miss signs of delayed gastric emptying, which can cause aspiration, nausea, vomiting, or abdominal distension. Gastric residuals should be checked every 4 hr.
Choice B reason: Returning gastric contents if residual is less than 250 mL is not advisable, as it can increase the risk of infection, contamination, or electrolyte imbalance. Gastric contents should be discarded if residual is more than 100 mL.
Choice C reason: Measuring the pH of gastric residual every 24 hr is not necessary, as it does not reflect the effectiveness or tolerance of the feeding. The pH of gastric residual should be checked before each feeding or every 6 to 8 hr to confirm tube placement and prevent misconnection.
Choice D reason: Flushing the tube with 15 mL of water every 4 hr is a correct action, as it can prevent clogging, maintain patency, and clear the tube of formula residue. Water should also be used to flush the tube before and after each medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Using an electronic device is not a reliable method for measuring blood pressure because it may give inaccurate readings due to movement, noise, or battery issues. An electronic device should be calibrated regularly and compared with a manual device.
Choice B reason: Inflating the cuff to 140/90 mmHg is not a correct procedure for measuring blood pressure because it may cause discomfort and false readings. The cuff should be inflated to about 20 to 30 mmHg above the expected systolic pressure or until the pulse disappears.
Choice C reason: Placing the cuff on the upper arm is a correct procedure for measuring blood pressure because it ensures that the cuff is at the same level as the heart and that the brachial artery is compressed. The cuff should be snug and fit around 80% of the arm circumference.
Choice D reason: Measuring blood pressure after exercise is not a good time for measuring blood pressure because it may reflect a temporary increase due to physical activity. Blood pressure should be measured after resting for at least 5 minutes in a quiet and comfortable environment.
Correct Answer is C
Explanation
Choice Areason: Increasing phosphorus intake is not advisable for clients with chronic kidney disease, as they may have hyperphosphatemia, a condition of high phosphorus levels in the blood. Hyperphosphatemia can cause bone loss, calcification of soft tissues, and itching.
Choice Breason: Increasing potassium intake is not advisable for clients with chronic kidney disease, as they may have hyperkalemia, a condition of high potassium levels in the blood. Hyperkalemia can cause muscle weakness, numbness, tingling, and cardiac arrest.
Choice C reason: Limiting protein intake is advisable for clients with chronic kidney disease, as protein metabolism produces urea, which is excreted by the kidneys. High protein intake can increase the workload and damage of the kidneys, and cause uremia, a condition of high urea levels in the blood. Uremia can cause nausea, vomiting, fatigue, and mental confusion.
Choice D reason: Limiting calcium intake is not advisable for clients with chronic kidney disease, as they may have hypocalcemia, a condition of low calcium levels in the blood. Hypocalcemia can cause muscle spasms, seizures, and cardiac arrhythmias.
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