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: Elevating the head of the client's bed can help prevent aspiration and facilitate swallowing. The nurse should keep the client's head elevated at least 30 degrees during and after feeding, and check for signs of aspiration, such as coughing, choking, or wheezing.
Choice B reason: Using a syringe to give the client fluids is not a safe method, as it can cause the fluids to enter the airway too quickly and cause aspiration. The nurse should use a spoon or a cup to give the client fluids, and thicken them if needed to make them easier to swallow.
Choice C reason: Instructing the client to chew on the left side of their mouth is not a good idea, as the left side is paralyzed and has reduced sensation. The client may not be able to chew or feel the food on that side, and may accidentally bite their tongue or cheek. The nurse should instruct the client to chew on the right side of their mouth, which is unaffected by the stroke.
Choice D reason: Instructing the client to swallow with their head tilted back is not a good practice, as it can open the airway and allow food or liquid to enter the lungs. The nurse should instruct the client to swallow with their head tilted slightly forward, which can close the airway and direct the food or liquid to the esophagus.
Correct Answer is A
Explanation
Choice A reason: A low-protein diet is essential for clients who have PKU, as they cannot metabolize the amino acid phenylalanine. High levels of phenylalanine can cause intellectual disability and other neurological problems. A low-protein diet should be started before pregnancy and maintained throughout pregnancy to prevent fetal harm.
Choice B reason: Serum bilirubin is not related to PKU. It is a product of red blood cell breakdown and is elevated in conditions such as jaundice, liver disease, or hemolytic anemia. It does not need to be monitored routinely in clients who have PKU.
Choice C reason: Diet sodas are not recommended for clients who have PKU, as they often contain artificial sweeteners such as aspartame, which is a source of phenylalanine. Diet sodas should be avoided completely or consumed very sparingly by clients who have PKU.
Choice D reason: Breastfeeding will not prevent the baby from developing PKU, as PKU is a genetic disorder that is inherited from both parents. If both parents have PKU, the baby will have a 100% chance of having PKU. If one parent has PKU and the other is a carrier, the baby will have a 50% chance of having PKU. If one parent has PKU and the other is not a carrier, the baby will not have PKU but will be a carrier. Breastfeeding may provide some benefits for the baby, such as immunity and bonding, but it will not affect the baby's PKU status.
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