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 A
Explanation
Choice A reason: Tapioca is a gluten-free food that can be recommended for a client who has celiac disease. Tapioca is a starch extracted from the cassava root, which is a tuber plant. Tapioca can be used to make puddings, breads, flours, and pearls.
Choice B reason: Barley is not a gluten-free food that can be recommended for a client who has celiac disease. Barley is a cereal grain that contains gluten, which is a protein that can trigger an immune response and damage the small intestine in people who have celiac disease. Barley should be avoided or replaced with gluten-free grains, such as rice, quinoa, or buckwheat.
Choice C reason: Cold cuts are not gluten-free foods that can be recommended for a client who has celiac disease. Cold cuts are sliced meats that are often processed and cured with additives, such as fillers, binders, and preservatives, that may contain gluten. Cold cuts should be avoided or checked for gluten-free labels before consuming.
Choice D reason: Flavored chips are not gluten-free foods that can be recommended for a client who has celiac disease. Flavored chips are snack foods that are often made from potatoes, corn, or rice, which are gluten-free ingredients, but they may also contain seasonings, spices, and sauces that may contain gluten. Flavored chips should be avoided or checked for gluten-free labels before consuming.
Correct Answer is D
Explanation
Choice A reason: BMI of 18.5 is at the lower end of the normal range (18.5-24.9), but it does not indicate severe malnutrition.
Choice B reason: Potassium 3.7 mEq/L is within the normal range (3.5-5.0), and it does not indicate electrolyte imbalance due to malnutrition.
Choice C reason: Phosphorus 3.5 mg/dL is within the normal range (2.5-4.5), and it does not indicate mineral deficiency due to malnutrition.
Choice D reason: Albumin 2.5 g/dL is below the normal range (3.5-5.0), and it indicates protein deficiency due to malnutrition. Albumin is a major protein in blood plasma that helps maintain fluid balance, transport hormones, and fight infections. Low albumin levels can cause edema, weakness, infection, and poor wound healing.
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