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?
Measure the client's gastric residual every 12 hr.
Keep the client's head elevated at 15° during feedings.
Obtain the client's electrolyte levels every 4 hr.
Flush the client's tube with 30 mL of water every 4 hr.
The Correct Answer is D
A) Measure the client's gastric residual every 12 hr: While monitoring gastric residual volume is important to prevent complications such as aspiration or gastric distention, it is typically done prior to each intermittent feeding, not every 12 hours for clients receiving continuous enteral feedings. Continuous feeding does not necessitate less frequent monitoring of gastric residuals.
B) Keep the client's head elevated at 15° during feedings: Elevating the client's head during feedings helps reduce the risk of aspiration. However, this action is not specific to initiating continuous enteral feedings and should be maintained throughout the client's enteral feeding regimen.
C) Obtain the client's electrolyte levels every 4 hr: Monitoring electrolyte levels every 4 hours is not necessary as part of routine care for a client initiating continuous enteral feedings. While electrolyte levels may be monitored periodically, the frequency would depend on the client's clinical condition and the healthcare provider's orders.
D) Flush the client's tube with 30 mL of water every 4 hr: Flushing the client's tube with water helps maintain patency and prevent clogging, which is especially important for clients receiving continuous enteral feedings. This action helps ensure that the tube remains clear and functional, allowing for uninterrupted delivery of the enteral feeding solution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["42"]
Explanation
The nurse should set the IV pump to deliver approximately 42 mL/hr.
Here's the calculation:
Total volume of infusion (mL): 1,000 mL
Infusion time (hours): 24 hours
Flow rate (mL/hr) = Total volume (mL) / Infusion time (hours)
Flow rate (mL/hr) = 1,000 mL / 24 hours = 41.6666667 mL/hr (round to nearest whole number as requested)
Therefore, the nurse should set the pump to deliver 42 mL/hr.
Correct Answer is A
Explanation
A) "Your baby should wet 6 to 8 diapers per day":
This response is correct. One way to determine if a breastfed baby is getting enough milk is by monitoring the number of wet diapers. A newborn who is adequately breastfeeding typically wets at least 6 to 8 diapers per day, indicating sufficient fluid intake and adequate hydration.
B) "Your baby should sleep at least 6 hours between feedings":
This statement is inaccurate and does not provide an appropriate measure of whether the baby is getting enough breast milk. Newborns typically feed frequently, often every 2 to 3 hours, and it is normal for them to wake for feeds during the night. Using sleep patterns alone to assess feeding adequacy is not reliable and can lead to inadequate milk intake.
C) "Your baby should burp after each feeding":
While burping is a common practice after feeding to help prevent discomfort from trapped air, it is not an indicator of whether the baby is getting enough breast milk. Burping is more related to gastrointestinal comfort rather than feeding adequacy.
D) "Your baby should have a wake cycle of 30 to 60 minutes after each feeding":
This statement does not accurately assess feeding adequacy. While it's normal for babies to have awake periods after feeding, the duration of these wake cycles alone does not indicate whether the baby is getting enough breast milk. Monitoring diaper output and weight gain are more reliable indicators of feeding adequacy.
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