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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice Arationale:
Rye toast with herbal tea is also not appropriate for someone with celiac disease. Rye bread contains gluten, and even though herbal tea is gluten-free, the combination with rye toast would still be harmful to the client.

Choice Brationale:
Graham crackers with peanut butter are not suitable for a client with celiac disease. Graham crackers are typically made from wheat flour, which contains gluten, a protein that individuals with celiac disease must avoid to prevent intestinal damage.

Choice C rationale:
The correct choice is rice cereal with sliced bananas. Rice cereal is naturally gluten-free and therefore safe for individuals with celiac disease. Sliced bananas can add flavor and nutrients to the meal without causing any harm to the client's condition.
Choice D rationale:
Poached eggs with wheat bagel is an unsuitable option. Wheat bagels contain gluten, which is harmful to individuals with celiac disease. Even though poached eggs are gluten-free, the risk of cross-contamination from the wheat bagel would be too high for this client.

A. "Maintain a low-protein diet." B. "Do not eat grapefruit while taking this medication." C. "Avoid aged cheeses while taking this medication." D. "Reduce intake of high-calorie foods."

Correct Answer is C

Explanation

Choice A rationale:
Maintaining a low-protein diet is not the appropriate instruction for a client taking a monoamine oxidase inhibitor (MAOI). While dietary restrictions are associated with MAOIs, it's primarily focused on avoiding foods rich in tyramine, which is not limited to just protein-containing foods.
Choice B rationale:
Not eating grapefruit while taking medication is generally applicable advice, but it is not specific to MAOIs. Grapefruit can interfere with the metabolism of certain medications by inhibiting specific enzymes. However, it's not a concern solely related to MAOIs.
Choice C rationale:
Avoiding aged cheeses while taking this medication is the correct instruction. Aged cheeses contain tyramine, which can lead to a hypertensive crisis when consumed with MAOIs. Tyramine interacts with MAOIs to increase blood pressure, potentially causing a serious reaction.
Choice D rationale:
Reducing intake of high-calorie foods is not a primary concern when taking MAOIs. The main dietary focus is on avoiding tyramine-rich foods to prevent dangerous interactions. High-calorie foods are not directly contraindicated with MAOIs.

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