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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Review with the client and spouse when to notify the physician: Appropriate
Rationale: It is essential to inform the client and their spouse about signs and symptoms that would require notifying the physician, such as increased pain, fever, or unusual symptoms. This helps ensure the client can recognize and report any issues promptly.
Instruct the client to sign their advance directive form: Inappropriate
Rationale: Advance directive forms should be completed well before a surgical procedure and are not typically addressed at the time of discharge following a minor same-day surgery. This is not directly related to the immediate postoperative care and discharge instructions.
Discuss appropriate wound care: Appropriate
Rationale: Providing instructions on how to care for the wound is crucial for preventing infection and promoting proper healing. This information is essential for the client's recovery and should be reviewed before discharge.
Educate on activity limitations: Appropriate
Rationale: Informing the client about activity restrictions helps prevent complications and supports appropriate healing. This education is crucial for ensuring the client follows guidelines that will aid in their recovery.
Provide information about dietary restrictions: Appropriate
Rationale: Depending on the type of surgery and sedation, there may be dietary restrictions or guidelines to follow. Providing this information helps the client manage their diet appropriately after discharge.
Correct Answer is C
Explanation
A. Ask why the client is taking steroid therapy: While understanding the reason for steroid therapy is important, it does not address the immediate need to manage the medication administration.
B. Notify the surgeon immediately: Notifying the surgeon might be necessary if there are specific concerns, but it is not the most immediate action regarding medication administration.
C. Administer an IV equivalent dose of Prednisone: Since the client is NPO, administering an oral medication could be contraindicated. Administering an IV equivalent ensures the client receives the necessary steroid therapy without risking complications from taking oral medication while fasting.
D. Give the oral steroid with a small sip of water: This may not be appropriate due to the NPO status, which typically restricts oral intake.
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