A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?
Obtain the client's electrolyte levels every 4 hr.
Measure the client's gastric residual every 12 hr.
Keep the client's head elevated at 15 during feedings.
Flush the client's tube with 30 mL of water every 4 hr.
The Correct Answer is B
Choice A rationale:
Obtaining the client's electrolyte levels every 4 hours is not standard practice when initiating continuous enteral feedings via a gastrostomy tube. While monitoring electrolytes is important, it's not done at such a high frequency unless there's a specific indication or concern.
Choice B rationale:
Measuring the client's gastric residual every 12 hours is a crucial action when initiating continuous enteral feedings. Gastric residual volume helps to assess the client's tolerance to the feeding, the rate of digestion and absorption, and the risk of aspiration. If the residual volume is too high, it could indicate feeding intolerance or delayed gastric emptying.
Choice C rationale:
Keeping the client's head elevated at 15 degrees during feedings is not standard practice for continuous enteral feedings. This angle could potentially promote reflux and increase the risk of aspiration. Instead, the head of the bed is usually elevated at least 30 degrees to help prevent reflux and aspiration.
Choice D rationale:
Flushing the client's tube with 30 mL of water every 4 hours is not a standard practice for continuous enteral feedings. Flushing the tube helps maintain its patency, but it's usually done before and after medication administration or as needed to prevent clogs, not on such a frequent schedule.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Using a washcloth to clean denture surfaces is not the recommended method as it can lead to scratches on the dentures, making them more susceptible to bacterial growth and staining.
Choice B rationale:
Wiping dentures before storing them in a dry container at night is the correct choice. This practice helps remove debris and bacteria, preventing them from accumulating overnight. Storing dentures in a dry container helps maintain their shape and prevents the growth of microorganisms that thrive in moist environments.
Choice C rationale:
Flossing dentures is not necessary and may damage or distort them. Unlike natural teeth, dentures do not have interdental spaces that require flossing.
Choice D rationale:
Wrapping gloved fingers with gauze to remove dentures is not the best practice, as it may cause damage to the dentures and also increases the risk of contamination.
Correct Answer is D
Explanation
Choice A rationale:
The statement "Meal replacement shakes can cause weight gain" is incorrect. Meal replacement shakes are designed to provide controlled portions of nutrients and can be helpful for weight management when used appropriately.
Choice B rationale:
While having a substantial breakfast can be beneficial for weight management, there's no hard and fast rule that it should be the biggest meal of the day. The timing and distribution of meals can vary based on individual preferences and lifestyles.
Choice C rationale:
Setting a weight loss goal of 2.5 pounds per week might be too aggressive for most individuals. A safe and sustainable rate of weight loss is generally around 1-2 pounds per week. Rapid weight loss can lead to muscle loss and other health issues.
Choice D rationale:
"Make sure to drink water with your meals" is a valid statement. Drinking water with meals can help promote satiety and control portion sizes. Additionally, staying hydrated is essential for overall health and can support weight loss efforts by reducing the likelihood of mistaking thirst for hunger.
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