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 C

Explanation

A. Knowing the consistency of the prescribed diet (e.g., pureed, mechanical soft, or regular) is important for planning the feeding process and ensuring that the diet meets the client's needs and restrictions. However, this information is secondary to assessing the client’s ability to safely chew and swallow.
B. While reviewing current medications is important for understanding potential drug interactions, side effects, or dietary restrictions, it is not the most immediate concern before feeding. Medications can influence appetite and digestion, but the priority is ensuring the client can safely handle the food.
C. This is the most critical information to obtain before feeding a debilitated client. Assessing the client's ability to chew and swallow helps prevent complications such as aspiration, choking, or aspiration pneumonia. The nurse should ensure that the client can safely manage the food given to them and that their swallowing mechanisms are functioning adequately.
D. While monitoring the respiratory rate and lung sounds is important for overall health assessment, it is not the immediate priority before starting a feeding session. However, it is important to monitor for signs of aspiration during and after feeding, as compromised swallowing can lead to aspiration pneumonia.

A. Ask the client to describe the pain experienced. B. Provide the client with a visual analog scale. C. Instruct the client in use of a numeric pain scale. D. Gently palpate the area and observe the response.

Correct Answer is A

Explanation

A. Asking the client to describe the pain is the most direct way to gather information about the quality of the pain. This approach allows the client to express characteristics such as whether the pain is sharp, dull, burning, aching, throbbing, or stabbing.
B. A visual analog scale (VAS) is useful for assessing the intensity of pain, not the quality. The VAS typically involves a line with endpoints representing no pain and worst possible pain, where the client marks their pain level.
C. The numeric pain scale is designed to measure the intensity of pain on a scale from 0 to 10, where 0 indicates no pain and 10 represents the worst pain imaginable. Like the VAS, this scale assesses pain intensity rather than quality.
D. Palpation and observing the client's response can help assess the location and intensity of pain, particularly if there are physical findings associated with the pain. However, this method does not provide information about the pain’s quality, such as its character or nature.

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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

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

Correct Answer is C

Explanation

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

Correct Answer is A

Explanation

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