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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A nurse administers the wrong medication to a client. – This is an example of negligence, as it represents a failure to follow the standard of care, potentially causing harm to the client. Nurses are expected to follow the "five rights" of medication administration to prevent errors.
B. A nurse applies wrist restraints to a client in violation of the facility's restraint use policy. – This is an example of false imprisonment, not negligence, as it involves restricting a client’s movement without proper justification.
C. A nurse touches a client in an offensive manner. – This is an example of battery, which is the intentional act of touching someone without their consent in a harmful or offensive way.
D. A nurse shares information about a client with family members without the client's consent. – This is an example of a breach of confidentiality, violating HIPAA regulations.
Correct Answer is C
Explanation
A. Inform the client they cannot refuse the surgery once the consent form has been signed. A client has the right to refuse treatment at any time, even after signing a consent form.
B. Explain the risks of the surgery to the client. The provider is responsible for explaining the risks, benefits, and alternatives of the procedure. The nurse's role is to witness consent and ensure the client understands.
C. Ensure the client has advance directives on file. Since the client has a serious, life-threatening illness (stage 4 cancer) and is undergoing surgery, it is important to verify whether they have advance directives, such as a living will or durable power of attorney for healthcare. These documents ensure that their wishes regarding medical treatment are followed.
D. Ask the client if they wish to be resuscitated in the event they stop breathing. While this is an important conversation, it is typically initiated by the provider. The nurse should confirm whether the client has a Do Not Resuscitate (DNR) order or advance directives in place.
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