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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Instructing a client with dysphagia to tilt their head back while swallowing can actually increase the risk of aspiration. This position opens the airway and makes it easier for food or liquid to enter the trachea instead of the esophagus, potentially leading to pneumonia or other respiratory complications.

Choice B rationale

Elevating the client's head of the bed to 45° during meals is a crucial intervention for clients with dysphagia. This semi-Fowler's position helps to utilize gravity to facilitate the passage of food and liquids down the esophagus and reduces the risk of aspiration into the airway. Maintaining this upright posture during and shortly after meals is essential for safe swallowing.

Choice C rationale

Alternating liquids and solids during meals can help manage dysphagia by reducing the bolus size and consistency that the client needs to manage at any given time. This strategy can prevent overwhelming the client's swallowing ability and decrease the risk of aspiration by allowing for better control over different food textures.

Choice D rationale

Encouraging the client to lie flat after meals is contraindicated for clients with dysphagia. Lying flat increases the risk of regurgitation and aspiration of food or liquids into the airway. Clients with swallowing difficulties should remain in an upright or semi-upright position for at least 30-60 minutes after eating to allow for proper digestion and reduce the risk of aspiration.

A. Minimize the use of seasoning. B. Limit finger foods. C. Serve small, frequent meals. D. Offer three large meals daily.

Correct Answer is C

Explanation

Choice A rationale

Minimizing the use of seasoning can decrease palatability and potentially reduce the client's food intake, negatively impacting their nutritional status. Flavorful foods can stimulate appetite and encourage better nutrient consumption.

Choice B rationale

Limiting finger foods may restrict autonomy and reduce intake for clients who have difficulty using utensils. Finger foods can provide independence and increase caloric intake for some individuals in long-term care.

Choice C rationale

Serving small, frequent meals can improve nutritional intake by preventing early satiety and providing a consistent supply of nutrients throughout the day. This approach is often beneficial for individuals with decreased appetite or difficulty tolerating large meals.

Choice D rationale

Offering three large meals daily might be overwhelming for some clients in long-term care who may have reduced appetites, slower digestion, or other medical conditions that make it difficult to consume large quantities of food at once.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dysphagia.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care of a client who is in a long-term care facility.To improve the client's nutritional status, which of the following nursing interventions should the nurse recommend adding to the plan? Provide soft foods.

Correct Answer is C

Explanation

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