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. Dry oral mucus membranes: This finding indicates dehydration rather than improvement. Effective treatment would result in the rehydration of mucous membranes.
B. Weight loss: Weight loss can be a sign of ongoing dehydration or fluid loss. Effective treatment would be indicated by weight stabilization or gain, not loss.
C. Jugular vein distention: Jugular vein distention typically indicates fluid overload or poor cardiac function, not improvement in dehydration. Effective rehydration would be associated with a return to normal vein appearance.
D. Daily urine output of 960 mL: This is the correct choice as it reflects adequate fluid intake and kidney function. For an average adult, a daily urine output of around 960 mL suggests proper hydration, indicating that interventions have been effective.

A. The client who takes medications for occasional anxiety B. The client admitted with a mild pleural effusion C. The client who has had diarrhea for the past 48 hours D. The client admitted with an acute renal injury E. The client admitted for treatment of asthmatic bronchitis

Correct Answer is ["C","D"]

Explanation

A. The client who takes medications for occasional anxiety: Anxiety medications are not typically associated with metabolic acidosis.
B. The client admitted with a mild pleural effusion: A mild pleural effusion is more related to fluid accumulation and respiratory issues rather than metabolic acidosis.
C. The client who has had diarrhea for the past 48 hours: Prolonged diarrhea can lead to loss of bicarbonate, resulting in metabolic acidosis.
D. The client admitted with an acute renal injury: Acute renal injury impairs the kidneys' ability to excrete acids and can lead to metabolic acidosis.
E. The client admitted for treatment of asthmatic bronchitis: Asthmatic bronchitis typically involves respiratory issues rather than metabolic acidosis.

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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

A nurse is providing care for a hospitalized client admitted with dehydration. Which assessment finding indicates interventions have been effective?

Correct Answer is D

Explanation

The nurse identifies that which of the following clients is at risk for developing metabolic acidosis? (Select All That Apply)

Correct Answer is ["C","D"]

Explanation

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