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.
Flush the client's tube with 30 mL of water every 4 hr.
Keep the client's head elevated at 15° during feedings.
Obtain the client's electrolyte levels every 4 hr.
The Correct Answer is B
Choice A reason: Measuring the client's gastric residual every 12 hr is not frequent enough to monitor the feeding tolerance and prevent aspiration. The nurse should measure the gastric residual before each intermittent feeding or every 4 to 6 hr during continuous feeding¹².
Choice B reason: Flushing the client's tube with 30 mL of water every 4 hr is an appropriate action to maintain the tube patency, prevent clogging, and hydrate the client. The nurse should flush the tube before and after each medication administration, feeding, or gastric residual check¹³.
Choice C reason: Keeping the client's head elevated at 15° during feedings is not sufficient to prevent reflux and aspiration. The nurse should elevate the head of the bed at least 30° to 45° during feedings and for at least 30 min to 1 hr after feedings¹⁴.
Choice D reason: Obtaining the client's electrolyte levels every 4 hr is not necessary unless the client has signs of fluid or electrolyte imbalance, such as edema, dehydration, or abnormal vital signs. The nurse should monitor the client's weight, intake and output, and laboratory values as ordered by the provider¹⁵.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these findings to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these findings to the provider as well, but they are not the most urgent ones.
Choice C reason: A temperature of 37.4° C (99.3° F) is slightly elevated, but not indicative of a fever or infection. The nurse should document this finding, but it does not require immediate follow-up.
Choice D reason: A blood pressure of 90/58 mm Hg is low, but not hypotensive. The nurse should document this finding, but it does not require immediate follow-up.
Correct Answer is D
Explanation
Choice A reason: Green tea is not a beverage that enhances the absorption of nonheme iron, but rather inhibits it. Green tea contains tannins, which are compounds that bind to iron and prevent its absorption. The nurse should advise the client to avoid drinking green tea or other beverages that contain tannins, such as black tea, with meals that contain iron.
Choice B reason: Coffee is not a beverage that enhances the absorption of nonheme iron, but rather inhibits it. Coffee also contains tannins, as well as caffeine, which can interfere with iron absorption. The nurse should recommend the client to limit or avoid coffee intake, especially with iron-rich foods.
Choice C reason: Milk is not a beverage that enhances the absorption of nonheme iron, but rather inhibits it. Milk contains calcium, which can compete with iron for absorption. The nurse should suggest the client to consume milk and other dairy products separately from iron-containing foods.
Choice D reason: Orange juice is a beverage that enhances the absorption of nonheme iron, as it is rich in vitamin C. Vitamin C can increase the absorption of nonheme iron by converting it from the ferric form to the more absorbable ferrous form. The nurse should encourage the client to drink orange juice or other citrus juices with meals that contain iron.
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