In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia.
Which of the following describes the nurse's best course of action?

Choice A rationale

Stating that the patient drank most liquids without difficulty is a general observation but lacks specific details about the quantity consumed and the type of diet. It provides limited nutritional information.

Choice B rationale

Saying the patient ate all her lunch is brief but doesn't specify the type or amount of food consumed. "Lunch" can vary greatly in nutritional content, making this documentation less informative.

Choice C rationale

This documentation provides specific details about the patient's intake, including the percentage of the heart-healthy diet consumed (50%), indicating the amount of solid food, and the exact volume of liquids ingested (360 mL). It also notes the absence of difficulty, offering a more comprehensive nutritional picture.

Choice D rationale

Documenting assistance with feeding a liquid diet and frequent choking is important for safety but doesn't quantify the amount of liquid consumed or the patient's overall nutritional intake from the meal.

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.