A nurse is preparing to administer intermittent tube feeding to a client who has a percutaneous gastrostomy tube. Which of the following actions should the nurse take?
Flush the client's tube with 5 mL of water.
Place the client in a supine position.
Check the pH level of the client's gastric contents.
Check the patency of the client's tube every 8 hr.
The Correct Answer is C
A. Flush the client's tube with 5 mL of water. – This is incorrect because the standard amount of water used to flush a feeding tube is typically 30–50 mL to maintain patency and prevent clogging.
B. Place the client in a supine position. – This is incorrect because the client should be placed in a semi-Fowler’s or Fowler’s position (at least 30–45 degrees) to reduce the risk of aspiration.
C. Check the pH level of the client's gastric contents. – This is the correct answer. Checking the pH of gastric contents (typically ≤5.5) helps confirm proper tube placement before administering feedings, reducing the risk of aspiration.
D. Check the patency of the client's tube every 8 hr. – This is incorrect because tube patency should be checked before each feeding or medication administration, not just every 8 hours.
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Related Questions
Correct Answer is D
Explanation
A. "Direct all communication through the client's family." While family members may assist in communication, they may omit, alter, or misunderstand medical information. Using a trained medical interpreter ensures accurate and confidential communication.
B. "Limit instructions to simple and short one-sentence instructions." While clear, simple instructions are helpful, language barriers still exist. This does not fully address the client’s difficulty in understanding.
C. "Ask a coworker who speaks the client's language to translate information." A coworker may not be a certified medical interpreter and could misinterpret critical information. Medical translation should always be done by a qualified interpreter.
D. "Find an available interpreter to help with communication." A trained medical interpreter provides accurate, unbiased, and professional translation, ensuring that the client fully understands their care and can make informed decisions.
Correct Answer is C
Explanation
A. "Remove clocks from the client's room." –
Removing clocks can increase confusion and disorientation. Instead, having a visible clock and calendar can help the client stay oriented.
B. "Check on the client frequently while he is in the restroom." –
While frequent monitoring is important, excessive surveillance may increase agitation and distress. A better alternative is to ensure the restroom is safe and accessible.
C. "Encourage physical activity throughout the day to expend energy." –
Engaging the client in physical activity helps reduce restlessness, promotes better sleep, and decreases the likelihood of agitation, which can reduce the need for restraints.
D. "Use full-length side rails on the client's bed." –
Full-length side rails can be considered a form of restraint as they may limit movement and increase the risk of falls or injury if the client tries to climb over them.
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