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.

Answer and Explanation

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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Correct Answer is ["320"]

Explanation

Net fluid balance = Total intake - Total output

Rationale:

Total intake:

IV fluids: 1,000 mL

Antibiotic infusion: 250 mL

Oral intake: 3 cups x 240 mL = 720 mL

Total intake = 1,000 + 250 + 720 = 1,970 mL Total output:

Urine: 1,200 mL

Vomiting: 300 mL Wound drainage: 150 mL

Total output = 1,200 + 300 + 150 = 1,650 mL

Net fluid balance = 1,970 mL - 1,650 mL = +320 mL

The patient has a positive fluid balance of 320 mL.

A. Initiate intravenous corticosteroids B. Provide supplemental oxygen and reassess in 30 minutes. C. Administer a second dose of albuterol immediately. D. Administer an oral antihistamine to reduce airway inflammation.

Correct Answer is A

Explanation

A. Intravenous corticosteroids are the next appropriate step to reduce inflammation in the airways and improve symptoms of asthma exacerbation.
B. Providing supplemental oxygen and reassessing in 30 minutes might be necessary, but corticosteroids are the priority in this case to address the underlying inflammation.
C. A second dose of albuterol may be considered, but corticosteroids should be administered as soon as possible to treat the inflammation in the airways.
D. An oral antihistamine is not indicated for asthma exacerbations, as it does not target the underlying inflammation in the airways.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["320"]

Explanation

Rationale:

Correct Answer is A

Explanation

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