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?
Check the pH level of the client's gastric contents.
Check the patency of the client's tube every 8 hr.
Place the client in a supine position.
Flush the client's tube with 5 mL of water.
The Correct Answer is D
A. Check the pH level of the client's gastric contents:
Checking the pH level of gastric contents is not typically necessary before administering intermittent tube feeding. pH testing of gastric contents is more commonly performed for clients with nasogastric tubes to confirm tube placement within the stomach. It is not routinely done before administering tube feeding through a percutaneous gastrostomy tube.
B. Check the patency of the client's tube every 8 hr:
While it is essential to check the patency of the tube regularly, every 8 hours may not be frequent enough, especially for clients receiving intermittent tube feedings. Tube patency should be checked before and after each feeding or medication administration to ensure proper function and prevent complications.
C. Place the client in a supine position:
Placing the client in a supine position is not specifically indicated for administering intermittent tube feedings. The client's position during tube feeding administration depends on individual factors such as comfort, mobility, and risk of aspiration. The nurse should position the client in a semi-upright or upright position (typically at a 30-45 degree angle) to reduce the risk of aspiration.
D. Flush the client's tube with 5 mL of water.
Flushing the client's tube with water helps ensure its patency and removes any residual feeding solution or gastric contents, reducing the risk of clogging and infection. Flushing with 5 mL of water is a common practice to maintain tube patency and should be done before and after each feeding and medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Metabolic syndrome: Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of cardiovascular disease, stroke, and type 2 diabetes. The conditions include increased blood pressure, high blood sugar levels, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Metabolic syndrome significantly increases the risk of developing cardiovascular disease by promoting atherosclerosis (hardening and narrowing of the arteries) and increasing the likelihood of developing other risk factors such as hypertension and diabetes.
B. Family history of alcohol use disorder: While excessive alcohol consumption can contribute to cardiovascular disease by raising blood pressure, increasing triglyceride levels, and promoting obesity, a family history of alcohol use disorder alone is not considered a direct risk factor for cardiovascular disease.
C. Participation in competitive sports: Regular physical activity, including participation in competitive sports, is typically associated with a reduced risk of cardiovascular disease. However, extreme levels of physical activity or certain types of competitive sports may pose risks, such as sudden cardiac events in individuals with underlying heart conditions. Overall, regular exercise is beneficial for cardiovascular health when performed in moderation and according to individual fitness levels.
D. Hypotension: Hypotension, or low blood pressure, is generally not considered a significant risk factor for cardiovascular disease. In fact, low blood pressure is often associated with a reduced risk of conditions such as heart attack and stroke. However, severe hypotension can indicate underlying health issues and may require medical evaluation and management.
Correct Answer is D
Explanation
A. A feeling of swelling in the feet: Swelling in the feet can be caused by various factors such as fluid retention, circulatory issues, or certain medical conditions like venous insufficiency. It is not a typical symptom of anaphylaxis, which usually involves more generalized symptoms such as hives, itching, swelling of the face or throat, difficulty breathing, and a drop in blood pressure.
B. Pain at the injection site: Pain at the injection site is a common side effect of receiving an injection or medication. It occurs due to tissue irritation or trauma from the needle. While allergic reactions can cause localized redness, swelling, or itching at the injection site, severe pain alone is not a hallmark symptom of anaphylaxis.
C. A sudden decrease in heart rate: Anaphylaxis typically leads to an increase in heart rate (tachycardia) rather than a decrease. This increase in heart rate is a response to the body's attempt to compensate for the drop in blood pressure caused by anaphylaxis. Bradycardia (a decrease in heart rate) is not a typical feature of anaphylaxis unless it occurs very late in a severe reaction due to profound circulatory collapse.
D. A sharp decrease in blood pressure: This choice is indicative of an understanding of possible anaphylaxis. Anaphylaxis can cause a rapid and severe drop in blood pressure, known as hypotension. This drop in blood pressure is often a key feature of anaphylaxis and can lead to symptoms such as dizziness, fainting, confusion, and shock.
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