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 C

Explanation

A. Calcium: Thiazide diuretics can increase calcium levels, but the primary concern is the potential loss of potassium.
B. Selenium: This is not directly related to thiazide diuretic therapy and does not address the primary electrolyte imbalance.
C. Potassium: This is the correct choice. Thiazide diuretics can cause hypokalemia (low potassium levels). Encouraging potassium-rich foods helps to counteract this side effect.
D. Bicarbonate: While bicarbonate can be important for acid-base balance, it is not the primary concern with thiazide diuretics, which typically affect potassium levels.

A. Hypernatremia B. Hyperglycemia C. Hypercalcemia D. Hyperkalemia

Correct Answer is B

Explanation

A. Hypernatremia: This condition involves elevated sodium levels, which is not directly addressed by the insulin and dextrose order.
B. Hyperglycemia: While dextrose can exacerbate hyperglycemia, the order of insulin and dextrose is not for managing hyperglycemia but for another purpose.
C. Hypercalcemia: This condition involves elevated calcium levels and is not related to the use of insulin and dextrose.
D. Hyperkalemia: The administration of regular insulin with dextrose is often used to manage hyperkalemia. Insulin helps shift potassium into cells, while dextrose prevents hypoglycemia resulting from the insulin.

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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 C

Explanation

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Correct Answer is B

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