A nurse is providing care for a client after a stroke who has dysphagia and requires a gastrostomy tube for feeding and medications.
The client is admitted to the Medical-Surgical floor following the placement of a percutaneous endoscopic gastrostomy (PEG) tube.
Which intervention should the nurse include in the client's plan of care?
Use sterile water to irrigate the tube.
Keep the head of the bed elevated at least 30 degrees at all times.
Moisten the client's lips with lemon glycerin swabs.
Measure the client's abdominal girth.
The Correct Answer is B
Choice A rationale
Sterile water is not the preferred solution for routine irrigation of a gastrostomy tube. Typically, tap water is recommended for irrigation in most home and long-term care settings for established PEG tubes, as it is cost-effective and generally safe. Sterile water is usually reserved for initial post-operative irrigation or in immunocompromised patients as per specific physician orders.
Choice B rationale
Keeping the head of the bed elevated at least 30 degrees is crucial for a client with a gastrostomy tube, especially one who has dysphagia and is at high risk for aspiration. Elevating the head of the bed helps to prevent reflux of stomach contents into the esophagus and subsequent aspiration into the lungs, reducing the risk of aspiration pneumonia. This position should be maintained during and after feedings and medication administration.
Choice C rationale
While maintaining oral hygiene is important for all patients, including those with gastrostomy tubes, moistening the client's lips with lemon glycerin swabs is generally discouraged. Lemon glycerin swabs can dry out the mucous membranes of the mouth and may not provide adequate hydration. Plain water or a moisturizing oral swab is a better choice for maintaining oral comfort.
Choice D rationale
Measuring the client's abdominal girth can be a useful assessment for detecting abdominal distension, which might indicate feeding intolerance or other complications related to the gastrostomy tube. However, it is not a primary intervention immediately following PEG tube placement. Ensuring proper positioning to prevent aspiration is a more critical initial intervention for a client with dysphagia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While prostate enlargement is common in older men, it is not typically directly associated with bilateral gynecomastia. Gynecomastia primarily involves breast tissue enlargement due to hormonal imbalances, not glandular changes related to the prostate. Recommending prostate screening solely based on gynecomastia is not the most direct or scientifically sound approach.
Choice B rationale
Acknowledging gynecomastia as benign breast enlargement without further investigation might be premature. While some cases in older men are benign and related to aging, it can also be a symptom of underlying medical conditions or medication side effects that require evaluation. Dismissing it without investigation could miss a treatable cause.
Choice C rationale
A mammogram is a screening tool for breast cancer, which is rare in men but possible. However, gynecomastia is characterized by benign glandular tissue proliferation, distinct from the tissue changes typically associated with male breast cancer. While a physician might order one to rule out malignancy, it's not the initial recommended action based solely on the finding of bilateral gynecomastia.
Choice D rationale
Gynecomastia in men can result from various hormonal changes, including a decrease in testosterone levels relative to estrogen, or an increase in estrogen production. Certain medical conditions and medications can also disrupt hormonal balance. Recommending a physician visit to investigate potential underlying causes of hormonal changes is the most appropriate initial action to determine the etiology of the gynecomastia and guide further management.
Correct Answer is D
Explanation
Choice A rationale
Introducing whole milk at 6 months is generally too early. At this age, an infant's primary nutrition should still come from breast milk or formula, which are specifically formulated to meet their developmental needs. The infant's digestive system is still maturing and may not be fully ready to process the higher protein and fat content of whole cow's milk.
Choice B rationale
Transitioning to whole milk at 8 months is also typically premature. While some infants might show readiness signs earlier, the American Academy of Pediatrics recommends waiting until closer to 12 months. Introducing whole milk too soon can displace the intake of breast milk or formula, potentially leading to deficiencies in essential nutrients like iron.
Choice C rationale
Waiting until 10 months is closer to the recommended timeframe, but most guidelines still advise waiting until 12 months. This allows the infant's digestive system more time to mature and ensures they receive optimal nutrition from breast milk or formula for a longer duration. Early introduction of whole milk doesn't offer any significant nutritional advantages over breast milk or formula during this period.
Choice D rationale
The American Academy of Pediatrics recommends transitioning to whole cow's milk around 12 months of age for most infants. By this time, their digestive system is more mature and capable of handling the nutrients in whole milk. Additionally, most infants at this age are consuming a wider variety of solid foods, which helps ensure they are meeting their nutritional needs beyond just milk.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.