The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding?
Measure vital signs.
Lower the head of the bed.
Verify tube patency.
Assist the client to a prone position.
The Correct Answer is C
C. Before administering a feeding through a gastrostomy tube, it is essential to verify that the tube is patent (open and unobstructed). Tube patency ensures that the feeding formula or medication can flow freely into the stomach or intestines without encountering any blockages or resistance. The nurse should flush the tube with water to check for patency and ensure proper functioning before initiating the feeding.
A. Vital signs are typically assessed for overall health monitoring and to detect any immediate changes in the client's condition. However, they are not specifically required before every feeding via gastrostomy tube unless there are specific concerns about the client's stability.
B. This option is not typically necessary before administering a feeding through a gastrostomy tube. In fact, elevating the head of the bed to at least 30 to 45 degrees is often recommended during and after feeding to minimize the risk of aspiration. This position helps to promote digestion and reduce the likelihood of reflux or regurgitation of the feeding.
D. Assisting the client to a prone (face-down) position is unnecessary and potentially unsafe before administering a feeding through a gastrostomy tube. The recommended position for feeding via gastrostomy tube is typically semi-Fowler's position (elevated head of the bed), which helps prevent aspiration and facilitates digestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.
C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.
E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.
A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.
D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.
Correct Answer is B
Explanation
B. Expected outcomes are specific, measurable criteria used to determine goal achievement. These outcomes are set during the planning phase of the nursing process in collaboration with the client. During evaluation, the nurse compares the client's actual progress with these expected outcomes. This assessment helps determine whether the goals were met, partially met, or not met, which guides further nursing actions.
A. During the evaluation phase, the nurse assesses the effectiveness of these interventions in achieving the desired outcomes rather than the interventions themselves. The focus is on determining whether the interventions were appropriate, timely, and effective in meeting the client's goals.
C Definitions typically refer to the meaning or understanding of terms used in the nursing process, such as nursing diagnoses or medical conditions. They provide clarity and context to ensure accurate assessment, planning, and intervention. However, definitions themselves are not directly evaluated in the evaluation phase of the nursing process.
D. In the evaluation phase, the nurse assesses the client's response to interventions aimed at addressing these diagnoses. The focus is on determining the effectiveness of the care provided rather than evaluating the diagnoses themselves.
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