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 A
A. Check the pH level of the client's gastric contents: To verify that the tip of the gastrostomy tube is still in the stomach, the nurse should aspirate a small amount of gastric contents and test the pH. Gastric secretions are typically acidic (pH of 5 or less), whereas intestinal or respiratory secretions usually have a higher pH. This ensures the formula is delivered into the stomach and reduces the risk of aspiration.
B. Check the patency of the client's tube every 8 hr: For intermittent feedings, patency should be checked immediately before each feeding rather than on a set hourly schedule. For continuous feedings, patency and residual volumes are usually checked every 4 to 6 hours.
C. Place the client in a supine position: This is contraindicated. To prevent aspiration, the client should be placed in a semi-Fowler's or high-Fowler's position (head of the bed elevated at least 30° to 45°) during the feeding and for 30 to 60 minutes afterward.
D. Flush the client's tube with 5 mL of water: While flushing is necessary to maintain patency, 5 mL is insufficient. The standard practice is to flush with 30 mL of water before and after each intermittent feeding and whenever the feeding is interrupted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use trochanter rolls beside the client's legs.
Trochanter rolls are supportive devices placed alongside the client's hips and thighs to prevent external rotation of the hips and maintain proper alignment of the legs. They help prevent hip abduction and rotation, which can lead to hip dislocation or pressure injuries, especially in immobile clients. Therefore, using trochanter rolls is essential in the care of immobile clients to maintain proper alignment and prevent complications.
B. Place the client's arms at their side when turning them: Placing the client's arms at their side during turning may limit movement and comfort. Instead, the nurse should support the client's arms in a position that promotes comfort and maintains proper alignment.
C. Cross the client's ankles when lying supine: Crossing the client's ankles can lead to compromised circulation and pressure on the bony prominences of the ankles, increasing the risk of pressure injuries. It is not recommended to cross the client's ankles in the supine position.
D. Logroll the client every 4 hr: Logrolling is a technique used to move clients with suspected spinal cord injuries while maintaining spinal alignment. However, it is not necessary to logroll an immobile client every 4 hours unless there are specific indications, such as suspicion of a spinal injury. Frequent repositioning, including the use of trochanter rolls, is essential to prevent pressure injuries and maintain skin integrity but should be individualized based on the client's needs and condition.
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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