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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. The client adjusts the head of their bed to 90°: Adjusting the head of the bed to 90° is a correct action for clients with dysphagia as it helps facilitate swallowing by promoting an upright position, reducing the risk of aspiration.

B. The client drinks their thickened juice with a straw.

Drinking thickened liquids with a straw is not recommended for clients with dysphagia. Straws can increase the risk of aspiration, as they bypass the natural protection mechanisms in the mouth and throat that help prevent liquids from entering the airway. Therefore, the nurse should intervene and provide the client with an appropriate drinking cup instead of a straw when consuming thickened liquids.

C. The client tucks their chin when they swallow: Tucking the chin when swallowing is a recommended technique for clients with dysphagia, as it helps close off the airway and directs the food or liquid toward the esophagus, reducing the risk of aspiration.

D. The client takes frequent breaks while eating: Taking frequent breaks while eating is a beneficial strategy for clients with dysphagia, as it allows them to rest and swallow safely without feeling rushed or overwhelmed by large amounts of food or liquid.

A. Ask the family if they wish to assist in washing the client's body. B. Remove the client's dentures for their family to keep. C. Leave the client's eyes open until the family views the body. D. Turn overhead lights to a bright setting.

Correct Answer is A

Explanation

A. Asking the family if they wish to assist in washing the client's body:

This is an important first step because it respects the family's cultural or religious practices and allows them to participate in the care of their loved one if they choose. It sets the tone for sensitive and respectful postmortem care.

B. Removing the client's dentures for their family to keep:

Dentures are usually leftin the mouth tomaintain facial shape.However, this action is not the first priority.

C. Leaving the client's eyes open until the family views the body:

It is generally recommended to gently close the client's eyes after death as part of the postmortem care process. Leaving the eyes open might be distressing for the family, so this action should not be performed first.

D. Turn overhead lights to a bright setting.

Bright lighting may not be comforting for the family or create a peaceful environment. Dim or soft lighting is usually preferred to create a calming atmosphere during this sensitive time. Therefore, this is not the first action the nurse should take.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

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