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: Meal replacement shakes are typically calorie-controlled and aid in portion regulation; they do not inherently cause weight gain unless consumed excessively or with additional high-calorie foods.
Choice B rationale: Consuming the largest meal at breakfast supports metabolism, improves satiety, and reduces overall daily caloric intake, aligning with circadian rhythms and promoting effective weight management.
Choice C rationale: Safe weight loss recommendations are 1 to 2 pounds per week; setting a goal of 2.5 pounds exceeds guidelines, increasing risk of nutrient deficiencies and metabolic complications.
Choice D rationale: Drinking water with meals aids digestion and satiety but is not a primary behavioral modification for weight loss; hydration is important but not directly linked to meal timing strategies.
Correct Answer is D
Explanation
Choice Arationale:
Albumin in the urine is not an indication of normal kidney function. The presence of albumin in the urine, known as albuminuria, is a sign of kidney damage, especially in individuals with diabetes. It's essential for individuals with diabetes to monitor and manage their kidney health, as kidney damage is a common complication.
Choice Brationale:
Blood glucose levels between 200 and 212 milligrams per deciliter are higher than the recommended target range for individuals with type 1 diabetes. Maintaining blood glucose levels within a healthy range (typically 80-130 mg/dL fasting) is important to prevent complications.
Choice C rationale:
An HbA1c level of five percent is unrealistically low and not achievable. The HbA1c level reflects the average blood glucose level over the past two to three months. While lower HbA1c levels are associated with better diabetes control, aiming for an HbA1c of five percent would pose a risk of hypoglycemia and potential complications.
Choice D rationale:
The statement "I will have ketones in my urine if my blood glucose is maintained at 190 milligrams per deciliter" demonstrates an understanding of the relationship between high blood glucose levels and ketone production. Elevated blood glucose levels can lead to the breakdown of fats for energy, resulting in the production of ketones, which can be detected in the urine. Ketones in the urine can be a sign of inadequate diabetes management and a risk of diabetic ketoacidosis (DKA).
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