An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

Place client on her left side while delivering the bolus.

Ask the client to select a preferred flavor for the bolus.

Elevate head of bed 30 degrees for 1 hour after bolus.

Flush tubing with warm water before and after bolus.

Include amount of feeding when recording fluid Intake.

Answer and Explanation

Correct Answer : C,D,E

A.   Placing the client on her left side is not a standard practice for delivering enteral feedings. Generally, the client should be in a semi-Fowler’s position (head of bed elevated at 30-45 degrees) to minimize the risk of aspiration and aid in digestion.
B.   While asking for a preferred flavor may be appropriate for improving patient comfort and adherence to the feeding regimen, it is not always feasible or necessary, particularly if the client has limited ability to communicate or make choices.
C.   Elevating the head of the bed to 30 degrees for 1 hour after administering a bolus feeding helps to reduce the risk of aspiration and aids in digestion by allowing gravity to assist in moving the feeding into the stomach. This is a standard practice for patients receiving enteral feedings and is important for preventing complications like aspiration pneumonia.
D.   Flushing the tubing with warm water before and after administering the bolus is essential to ensure that the entire amount of feeding is delivered and to prevent clogging of the tube. This practice helps in maintaining tube patency and ensuring that the client receives the full intended dose of nutrition.
E.   It is important to record the amount of enteral feeding as part of the client’s total fluid intake. Accurate documentation helps in monitoring the client’s fluid balance and nutritional intake, which is critical for managing the client’s overall health and adjusting their care plan as needed.

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Correct Answer is D

Explanation

A. Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B. While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C. Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D. Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

A. Wear an emergency response pendant at home. B. Recommend installing grab bars by toilets, bathtub, and shower. C. Request that a family member move in with her. D. Encourage exercise to improve balance and mobility. E. Have the home health nurse assess the home for fall risks.

Correct Answer is ["A","B","D","E"]

Explanation

A. This device can be used to summon help quickly in case of a fall or other emergency.
B. Grab bars provide extra support and can help prevent falls in areas where the risk is high.
C. Request that a family member move in with her might be a solution for some people but it is not always practical or desirable. It's important to consider the client's preferences and independence when making recommendations.
D. Regular exercise can help strengthen muscles and improve balance, reducing the risk of falls.
E. A home health nurse can identify potential hazards in the home and make recommendations for modifications to improve safety.

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An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Correct Answer is D

Explanation

An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

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