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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Phenelzine belongs to a class of antidepressants known as monoamine oxidase inhibitors (MAOIs). MAOIs work by inhibiting the activity of the enzyme monoamine oxidase, which results in increased levels of certain neurotransmitters in the brain, such as serotonin, norepinephrine, and dopamine. However, MAOIs have a significant dietary restriction due to their interaction with tyramine-containing foods. Tyramine is a substance found in various foods and beverages and can lead to a sudden and dangerous increase in blood pressure when combined with MAOIs, resulting in a hypertensive crisis.

A) Pepperoni pizza: Pepperoni is a processed meat product that is high in tyramine. Additionally, pizza often contains aged cheeses, which are also rich in tyramine. Therefore, consuming pepperoni pizza while taking phenelzine poses a risk of hypertensive crisis due to the high tyramine content.

B) Strawberry yogurt: Yogurt, particularly varieties without added fruit or flavorings, is generally considered low in tyramine and is thus a safer option for individuals taking MAOIs. Additionally, fresh strawberries are also low in tyramine, making strawberry yogurt a suitable choice for someone on phenelzine therapy.

C) Smoked salmon: Smoked or cured fish, such as smoked salmon, is another food high in tyramine. Therefore, it is not recommended for individuals taking MAOIs due to the risk of hypertensive crisis.

D) Cheddar cheese: Aged cheeses like cheddar contain high levels of tyramine and should be avoided by individuals on MAOIs. Consuming cheddar cheese while taking phenelzine increases the risk of a hypertensive crisis.

A. Avoid serving sauces or gravies. B. Discourage the use of a straw. C. Serve the client hot meals. D. Offer the client frozen bananas as a snack.

Correct Answer is ["A","B","D"]

Explanation

A) Remove the bedpan from the client's sight: This action helps create a more pleasant and comfortable environment for the client during meals, which can enhance their appetite and willingness to eat. Removing unpleasant stimuli, such as a bedpan, from sight can help improve the overall dining experience for the client.

B) Provide mouth care before feeding: Proper oral hygiene is essential for maintaining the client's oral health and can help stimulate their appetite. Mouth care before feeding removes food particles and bacteria, improving the client's ability to taste and enjoy food. It also helps prevent infections and discomfort associated with poor oral hygiene, promoting better overall nutrition.

C) Assess for pain prior to mealtime: While assessing for pain is crucial for overall client care, it is not directly related to implementing a nutrition plan for a client at risk for malnutrition. However, pain assessment is important for identifying any discomfort that could interfere with the client's ability to eat and should be addressed promptly.

D) Administer antiemetics following the meal: Administering antiemetics following meals may be necessary for clients who experience nausea or vomiting during or after eating. Antiemetics can help manage these symptoms, allowing the client to retain food and improve their nutritional intake. However, the decision to administer antiemetics should be based on individual assessment and prescription by a healthcare provider.

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