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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. The client leans to the left side while sitting: While leaning to one side may indicate weakness or impaired balance, it is not as immediately concerning as the risk of aspiration. Addressing issues related to positioning and balance is important but may not pose an immediate threat to the client's safety.

B. The client coughs frequently while eating.

Coughing frequently while eating can indicate a risk of aspiration, which is a serious concern in stroke patients with left-sided weakness. Aspiration can lead to pneumonia and other respiratory complications. Therefore, it is crucial for the nurse to address this finding promptly to prevent potential respiratory compromise.

C. The client is consuming 25% of their meals: Poor oral intake and difficulty eating are concerning but do not pose an immediate threat to the client's safety compared to the risk of aspiration. However, addressing inadequate nutrition and hydration is essential for the client's overall health and recovery.

D. The client's blood pressure is 142/94 mm Hg: While monitoring blood pressure is important, especially in stroke patients who may have hypertension, the blood pressure reading provided does not indicate a hypertensive crisis or immediate risk to the client's safety. Therefore, it is not the priority finding compared to the risk of aspiration.

A. Place wet towels along the base of the door. B. Turn off any electrical equipment. C. Activate the facility's fire alarm. D. Direct a fire extinguisher at the fire.

Correct Answer is C

Explanation

A. Placing wet towels along the base of the door: While this action may help prevent smoke from entering or exiting the room, it is not the immediate priority. Activating the fire alarm takes precedence to alert others to the fire and initiate the appropriate response.

B. Turning off any electrical equipment: While turning off electrical equipment can reduce the risk of electrical fires, it is not the immediate priority. Activating the fire alarm is the first step to ensure the safety of everyone in the facility.

C. Activate the facility's fire alarm.

Activating the fire alarm is crucial because it immediately alerts others in the facility to the presence of a fire, enabling them to respond appropriately. This action initiates the facility's fire safety protocols, including evacuating the area and summoning professional assistance to extinguish the fire. The sooner the alarm is activated, the quicker the response can be, reducing the risk to individuals and property.

D. Directing a fire extinguisher at the fire: While using a fire extinguisher may be necessary to extinguish the fire, it should only be done after activating the fire alarm to ensure that emergency personnel are alerted and responding to the situation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Correct Answer is B

Explanation

A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory results of a female client who has liver dysfunction a receiving a continuous tube feeding. Which of the findings should the nurse identify as a protein deficiency?

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

A nurse is obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease?

A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is immobile. Which of the following interventions should the nurse plan to take to prevent plantar flexion contractures?