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.

Keep the client's head elevated at 15° during feedings.

Measure the client's gastric residual every 12 hr.

Flush the client's tube with 30 mL of water every 4 hr.

Answer and Explanation

The Correct Answer is D

A. Obtain the client's electrolyte levels every 4 hr. While monitoring electrolyte levels is important, obtaining them every 4 hours is excessive for a client who is stable and just starting enteral feedings. Typically, electrolyte levels are monitored based on clinical condition and provider orders.

B. Keep the client's head elevated at 15° during feedings. The client's head should be elevated at least 30 to 45 degrees during enteral feedings to reduce the risk of aspiration and improve gastric emptying. A position of only 15 degrees is insufficient for safety.

C. Measure the client's gastric residual every 12 hr. Gastric residuals should be assessed more frequently, especially in the initial stages of enteral feeding. It is typically recommended to check gastric residuals every 4 to 6 hours to ensure proper gastric emptying and tolerance to the feedings.

D. Flush the client's tube with 30 mL of water every 4 hr. Flushing the tube with water every 4 hours is a standard practice to maintain tube patency, prevent clogging, and ensure that the client receives adequate hydration.

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Correct Answer is C

Explanation

Dysphagia refers to difficulty or discomfort in swallowing. It can occur as a result of weakened or impaired muscles involved in swallowing, which is common after a stroke. When dysphagia is present, it can affect the function of the vocal cords and lead to changes in voice quality, including hoarseness. The hoarseness may be due to the entry of food or liquid into the airway during swallowing, causing irritation to the vocal cords.

Weight gain is not a typical manifestation of dysphagia. If dysphagia is severe and leads to food avoidance or restricted intake, weight loss may occur instead.

Continuous smiling is not a specific manifestation of dysphagia. It may be seen in some stroke survivors as a result of changes in facial muscle control, such as facial weakness or spasticity. However, it is not directly related to dysphagia.

Expressive aphasia refers to difficulty expressing thoughts or using language effectively. It is a common language impairment that can occur after a stroke, specifically affecting the ability to produce or articulate words and sentences. While it is a communication difficulty, it is not directly related to dysphagia, which specifically refers to difficulty swallowing.

A. Tachycardia B. Hypertension C. Distended neck veins D. Decreased respiratory rate

Correct Answer is A

Explanation

The expected finding in an older adult client with dysphagia and dehydration is tachycardia. Tachycardia, an increased heart rate, is a common finding in dehydration as the body tries to compensate for the decreased fluid volume.
The other choices (hypertension, distended neck veins, and decreased respiratory rate) are not typically associated with dehydration in this context.
here's an explanation of why these choices are incorrect:
1. Hypertension: Dehydration usually leads to a decrease in blood volume, resulting in low blood pressure rather than hypertension. Hypertension is not a typical finding in dehydration.
2. Distended neck veins: Dehydration causes a decrease in blood volume, which results in decreased venous return to the heart. Consequently, distended neck veins would not be an expected finding.
3. Decreased respiratory rate: Dehydration itself does not directly affect respiratory rate. However, severe dehydration can lead to electrolyte imbalances, such as hyponatremia (low sodium levels), which can affect brain function and potentially lead to changes in respiratory rate. However, decreased respiratory rate is not a common finding in dehydration alone.
It's important to remember that dehydration can have various signs and symptoms, including dry mucous membranes, decreased urine output, increased thirst, dry skin, dizziness, and confusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is recovering from a stroke. Which of the following findings is a manifestation of dysphagia?

Correct Answer is C

Explanation

A nurse is assessing an older adult client who has dysphagia and is experiencing dehydration. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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