A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

Check the gastric residual every 8 hr.

Change the feeding bag every 24 hr.

Flush the tube with sterile sodium chloride solution every 2 hr.

Position the head of the client's bed at 15.

Answer and Explanation

Correct Answer : B

Correct answer: B

A. Check the gastric residual every 8 hr:
Explanation: It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.

B. Change the feeding bag every 24 hr:
Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.

C. Flush the tube with sterile sodium chloride solution every 2 hr:
Explanation: While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.

D. Position the head of the client's bed at 15 degrees:
Explanation: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration.

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Correct Answer is C

Explanation

A. High-fiber cereals:
High-fiber cereals may not be suitable for a soft diet, as they can be challenging to chew and may not meet the texture requirements of a soft diet.

B. Raw vegetables:
Raw vegetables are generally not recommended for a soft diet, as they can be difficult to chew and digest. Cooking or steaming vegetables can make them softer and more suitable for a soft diet.

C. Ground beef:
This is the correct answer. Ground beef can be included in a soft diet, especially if it is cooked to a tender consistency. It provides a good source of protein while meeting the requirements of a soft-textured diet.

D. Fruit with the skin:
Fruits with skins may pose a challenge for individuals on a soft diet, as the skin can be difficult to chew and swallow. Choosing peeled or canned fruits without skins may be more appropriate.

A. Flush the tube with water. B. Measure stomach contents. C. Elevate the head of the bed. D. Return gastric content into the gastrostomy tube.

Correct Answer is A

Explanation

A. Flush the tube with water:
This is the correct action to take first. Flushing the tube with water ensures that the tube is clear and functional before administering the bolus enteral feeding.

B. Measure stomach contents:
This is not the first action to take. Before measuring stomach contents, it's important to confirm that the tube is patent and clear by flushing it with water.

C. Elevate the head of the bed:
While elevating the head of the bed is important during and after enteral feedings to reduce the risk of aspiration, it is not the first step. The initial focus should be on verifying the tube's patency.

D. Return gastric content into the gastrostomy tube:
If there is resistance or difficulty flushing the tube, returning gastric contents into the tube may be necessary, but it's not the first action. The first step is to attempt to clear the tube with water.

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A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

Nursing Test Bank

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