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.
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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 B
Explanation
Choice A rationale
Nutrisystems is a commercial weight loss program that provides pre-packaged meals. While it may be effective for some, it is not directly sponsored by the USDA and might not align with the specific dietary recommendations promoted by the government for overall health.
Choice B rationale
MyPlate is a nutritional guide developed by the United States Department of Agriculture (USDA). It is designed to help Americans make healthier food choices by illustrating the five food groups and providing recommendations on portion sizes and a balanced diet. This is a direct resource sponsored by the USDA.
Choice C rationale
Weight Watchers (now WW) is a commercial weight loss program that utilizes a points system to guide food choices and encourages group support. While it can be a helpful resource for weight management, it is not a USDA-sponsored program.
Choice D rationale
eDiets.com is a commercial website that offers various diet plans, recipes, and fitness advice. While it may provide useful information for some individuals, it is not a resource directly sponsored or developed by the USDA.
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