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 C
Explanation
A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:
While using an appropriately sized cuff is crucial for accurate blood pressure measurement, the width of the cuff should be about 40% of the circumference of the upper arm, not 50%. However, adjusting the cuff size is not the most immediate action to take when faced with an elevated blood pressure reading.
B. Reposition the client supine and recheck her BP:
Repositioning the client supine is not necessary for routine blood pressure measurement in a sitting position. Moreover, repositioning the client may not significantly affect the blood pressure reading, especially if the initial reading was obtained correctly.
C. Recheck the client's BP in her other arm for comparison.
When obtaining a blood pressure reading, it's important to confirm the accuracy of the measurement, especially if the reading is elevated. Checking the blood pressure in the other arm allows for comparison and helps identify any significant differences between the arms, which could indicate arterial abnormalities or other issues. This step ensures accuracy and helps in making appropriate clinical decisions.
D. Request that another nurse check the client's BP in 30 min:
Waiting 30 minutes to recheck the blood pressure is not the most appropriate action when faced with an elevated reading. Prompt reevaluation and comparison of blood pressure readings are essential for accurate assessment and timely intervention, especially if the initial reading indicates hypertension.
Correct Answer is A
Explanation
A. "Walk for 30 minutes three to five times each week."
Regular weight-bearing exercises, such as walking, are beneficial for maintaining bone density and reducing the risk of osteoporosis. Walking for 30 minutes three to five times per week can help strengthen bones, improve balance, and reduce the risk of fractures associated with osteoporosis.
B. "Perform water aerobics three times each week": While water aerobics is a beneficial form of exercise for overall health and fitness, it may not be as effective as weight-bearing exercises like walking for preventing osteoporosis. Water-based activities do not provide the same impact on bone density as weight-bearing exercises.
C. "Maintain a lean body mass": While maintaining a healthy body weight is important for overall health, particularly for reducing the risk of conditions like heart disease and diabetes, it may not specifically prevent osteoporosis. In fact, having a low body weight or being underweight can increase the risk of osteoporosis.
D. "Increase intake of vitamin B12": Vitamin B12 is important for various bodily functions, including nerve function and the formation of red blood cells, but it is not directly linked to the prevention of osteoporosis. Adequate calcium and vitamin D intake, along with weight-bearing exercise, are key factors in preventing osteoporosis.
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