A nurse is caring for a client receiving continuous enteral feedings via a gastrostomy tube. Which nursing intervention is most important to help prevent aspiration?

Discard the container of formula every 12 hours

Irrigate the tube with sterile water before administering medications

Measure & record the residual volume after each feeding

Keep head of bed elevated 30 degrees

Answer and Explanation

The Correct Answer is D

A. Discard the container of formula every 12 hours: While this is important for preventing contamination, it does not directly address the risk of aspiration.
B. Irrigate the tube with sterile water before administering medications: This helps maintain tube patency and prevent clogging but does not significantly impact the prevention of aspiration.
C. Measure & record the residual volume after each feeding: Monitoring residuals is crucial for assessing gastric emptying and preventing overfeeding but does not directly prevent aspiration.
D. Keep head of bed elevated 30 degrees: This is the correct choice. Elevating the head of the bed reduces the risk of aspiration by ensuring that gravity helps keep the feeding in the stomach and minimizes the risk of reflux into the esophagus.

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Correct Answer is D

Explanation

A. Continue monitoring the client: The client's vital signs, pale and cool skin, and low urine output suggest potential hypovolemic shock or other serious postoperative complications, requiring more immediate intervention than just continued monitoring.
B. Increase nasal oxygen flow rate to 8 L: While increasing oxygen may be necessary, the primary concern is the underlying cause of the client's symptoms, which may require more immediate intervention.
C. Place the client in high Fowler's position: This position may be beneficial for certain conditions but does not address the underlying issues suggested by the vital signs and physical findings.
D. Notify the surgeon as soon as possible: This is the correct choice. The client's hypotension, tachycardia, pale and cool skin, and low urine output indicate potential complications that need immediate evaluation by the surgeon.

A. Decrease the TPN rate to 60 ml/hr B. Replace TPN infusion with an intravenous dextrose solution C. Begin infusion of 0.9% normal saline at 30 ml/hr D. Discontinue TPN infusion E. Discontinue TPN infusion

Correct Answer is B

Explanation

A. Decrease the TPN rate to 60 ml/hr: Gradually decreasing the TPN rate is a common practice, but it is typically done in conjunction with transitioning to another form of nutrition, not as a standalone order.
B. Replace TPN infusion with an intravenous dextrose solution: This is the correct choice. When weaning off TPN, it is important to prevent hypoglycemia by replacing the TPN with a dextrose solution to maintain blood glucose levels while transitioning to oral or enteral feeding.
C. Begin infusion of 0.9% normal saline at 30 ml/hr: While saline may be used for hydration, it does not address the need to manage blood glucose levels during the transition from TPN.
D. Discontinue TPN infusion: Discontinuing TPN abruptly can lead to complications such as hypoglycemia. It is important to gradually taper off TPN while replacing it with a dextrose solution.

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A nurse is caring for a client receiving continuous enteral feedings via a gastrostomy tube. Which nursing intervention is most important to help prevent aspiration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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