A nurse is preparing to administer an enteral feeding to a patient with a gastrostomy tube. Before starting the feeding, which of the following actions should the nurse take to ensure patient safety?
Administer the feeding solution directly from the refrigerator.
Flush the tube with 10 mL of cold water
Position the patient supine at 30 degrees.
Verify the pH of gastric aspirate is less than 5.0.
The Correct Answer is D
A. Administering feeding solution directly from the refrigerator can cause discomfort to the patient and increase the risk of gastric upset.
B. Flushing the tube with cold water is not appropriate, as it may irritate the stomach and cause discomfort.
C. Positioning the patient supine at 30 degrees is unsafe, as it increases the risk of aspiration. The patient should be at a higher angle, typically 30-45 degrees.
D. Verifying the pH of gastric aspirate is crucial to ensure the feeding tube is in the correct position and to prevent aspiration of feeding material into the lungs.
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Related Questions
Correct Answer is D
Explanation
A. A blood glucose level of 140 mg/dL is too low for DKA, which typically involves hyperglycemia above 250 mg/dL.
B. A blood glucose level of 180 mg/dL and normal ketone levels are inconsistent with DKA, as DKA involves both high glucose and elevated ketones.
C. A blood glucose level of 250 mg/dL with normal ketone levels would not suggest DKA. Elevated ketones are a critical part of diagnosing DKA.
D. A blood glucose level of 600 mg/dL with elevated ketone levels in blood and urine confirms DKA, a life-threatening complication of Type 1 diabetes.
Correct Answer is ["E","F"]
Explanation
A. Frequent headaches can be a symptom of hypertension but are not specific to poorly managed hypertension.
B. Blood pressure consistently at goal indicates good management of hypertension.
C. Normal renal function tests suggest that there has been no damage to the kidneys, a common consequence of poorly controlled hypertension.
D. Steady weight with no recent gain suggests good management of overall health, which can contribute to better blood pressure control.
E. Proteinuria indicates kidney damage, often a result of uncontrolled hypertension.
F. Left ventricular hypertrophy (LVH) is a sign of chronic hypertension and indicates poor management, as it results from the heart working harder to pump blood against increased pressure.
G. Absence of retinal changes on fundoscopic exam indicates that there is no evidence of hypertensive retinopathy, suggesting good hypertension management.
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