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 D

Explanation

A. Extend the client's neck while securing the ties: This action can compromise the client's airway and is not recommended during tracheostomy tie changes. The client's neck should be in a comfortable, neutral position during the procedure.

B. Use a quick-release knot to secure the ties: Quick-release knots are not typically used for securing tracheostomy ties. Instead, a secure knot that can be easily tied and untied is preferred to ensure the stability of the tracheostomy tube.

C. Allow space for three fingers under the ties when securing.

Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.

D. When changing tracheostomy ties, it is essential to maintain airway security and prevent accidental dislodgement of the tracheostomy tube. The nurse should secure the new ties first before removing the old ones to ensure the tracheostomy remains stable.

A. Antibiotic medication can be taken with or without food, B. The steroid dose will decrease each day. C. Adjust the oxygen flow rate as needed to ease breathing. D. Antibiotic therapy should be taken for 10 days. E. Store the oxygen cylinder wrench with the oxygen tank. F. Steroid medication should be taken in the morning. G. Ensure the oxygen delivery system is at least 8 feet from any heat source.

Correct Answer is ["B","C","F","G"]

Explanation

A. Antibiotic medication can be taken with or without food.

This statement is not specifically relevant to the discharge teaching for this client with pneumonia. However, the nurse should provide specific instructions regarding the administration of the antibiotic (cefazolin), which is typically administered intravenously in a healthcare setting and may not be taken orally at home.

B. The steroid dose will decrease each day.

Explanation: This information ensures that the client and caregiver are aware of the tapering regimen for the steroid medication (prednisone), which is essential to prevent adrenal insufficiency and other potential adverse effects associated with abrupt discontinuation.

C. Adjust the oxygen flow rate as needed to ease breathing.

Explanation: This information educates the client and caregiver on how to manage oxygen therapy effectively at home, ensuring optimal oxygen delivery and respiratory support.

D. Antibiotic therapy should be taken for 10 days.

The duration of antibiotic therapy for pneumonia depends on the specific antibiotic prescribed and the severity of the infection. The nurse should provide clear instructions based on the healthcare provider's prescription and guidelines.

E. Store the oxygen cylinder wrench with the oxygen tank.

While storing the oxygen cylinder wrench with the oxygen tank is a good practice, it is not directly related to discharge teaching for this client with pneumonia.

F. Steroid medication should be taken in the morning.

Explanation: Taking steroid medication (prednisone) in the morning helps minimize disruption of the body's natural cortisol rhythm and reduces the risk of insomnia associated with steroid use.

G. Ensure the oxygen delivery system is at least 8 feet from any heat source.

Explanation: Proper storage and placement of the oxygen delivery system reduce the risk of fire hazards associated with oxygen therapy, promoting safety within the home environment.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Correct Answer is ["B","C","F","G"]

Explanation

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