A nurse is initiating an intermittent enteral feeding for a client who has a new gastrostomy tube. Which of the following actions should the nurse take first?

Elevate the head of the bed.

Attach the barrel of the syringe to the tube after removing the plunger.

Insert air into the tube before pulling back gastric contents.

Flush the tube with 30 mL water.

Answer and Explanation

The Correct Answer is A

A. Elevate the head of the bed: Raising the head of the bed to at least 30 to 45 degrees is the first and most essential action to reduce the risk of aspiration during enteral feeding. This position helps ensure that the formula flows into the stomach by gravity and minimizes the potential for reflux of gastric contents into the lungs, which can lead to aspiration pneumonia.
B. Attach the barrel of the syringe to the tube after removing the plunger: This step is necessary for gravity-based enteral feeding when using a syringe. However, it should only be done after confirming tube placement and ensuring the patient is positioned properly. Attaching the syringe before proper safety precautions increases the risk of aspiration.
C. Insert air into the tube before pulling back gastric contents: Injecting air into the gastrostomy tube is part of the verification process to confirm tube placement, often followed by aspirating gastric contents. While this is important, it is not the very first action. The client's head must be elevated first to ensure safety before any manipulation of the tube begins.
D. Flush the tube with 30 mL water: Flushing is necessary to ensure tube patency and to prevent blockage before and after feedings. However, it is not the first step in the procedure. Elevating the head of the bed comes before flushing to prevent aspiration during any subsequent feeding or fluid administration.

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Correct Answer is C

Explanation

A. The client places the nipple shield under the nipple to collect wasted milk: The nipple shield is not designed to collect milk. Its primary purpose is to help the infant latch onto the breast more effectively, especially if the mother has difficulty with breastfeeding or if the infant has trouble latching. Placing the nipple shield under the nipple to collect milk would be an incorrect use of the device.
B. The client expresses breast milk into the nipple shield for storage: While expressing breast milk is a common practice, the nipple shield is not intended to be used for milk storage. Its role is to provide a barrier and support to facilitate feeding.
C. The client places the nipple shield over the nipple prior to feeding: This is the correct use of the nipple shield. It is designed to be placed over the nipple before feeding to help the infant latch effectively, especially for mothers with inverted or flat nipples, or when the infant has difficulty latching properly. The nipple shield supports a more effective breastfeeding experience.
D. The client uses the nipple shield to relieve breast engorgement: The nipple shield is not designed to relieve breast engorgement. While it can assist with latching, engorgement typically requires other interventions such as warm compresses, frequent breastfeeding, or expressing milk to alleviate the discomfort and restore normal breast tissue function.

A. "Consume ten percent of total calories from saturated fat." B. "Consume foods that are high in calcium." C. "Limit sodium intake to 3,200 milligrams per day." D. "Increase intake of refined carbohydrates."

Correct Answer is B

Explanation

A. "Consume ten percent of total calories from saturated fat": The DASH diet emphasizes reducing saturated fat intake to help lower blood pressure and reduce cardiovascular risk. Saturated fat should make up less than 6% of total daily calories. Consuming 10% of total calories from saturated fat exceeds this recommendation and can contribute to hypertension and atherosclerosis.
B. "Consume foods that are high in calcium": The DASH diet promotes the intake of calcium-rich foods, especially from low-fat or fat-free dairy products. Adequate calcium intake supports healthy blood pressure by helping to regulate vascular contraction and dilation. Including calcium-rich foods such as leafy greens, fortified plant milks, and dairy is an essential component of the DASH plan.
C. "Limit sodium intake to 3,200 milligrams per day": The DASH diet recommends limiting sodium intake to no more than 2,300 milligrams per day, with a more beneficial goal of 1,500 milligrams for individuals with hypertension. A sodium limit of 3,200 milligrams per day is too high and could undermine the blood pressure-lowering benefits of the DASH diet.
D. "Increase intake of refined carbohydrates": Refined carbohydrates such as white bread, pastries, and sugary cereals are discouraged in the DASH diet. These foods can lead to blood sugar spikes and are often low in fiber and essential nutrients. Instead, the diet recommends whole grains, fruits, and vegetables that provide complex carbohydrates and fiber for better heart health.

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A nurse is initiating an intermittent enteral feeding for a client who has a new gastrostomy tube. Which of the following actions should the nurse take first?

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