The nurse observes a client demonstrate self-administration of an 80 mL bolus feeding through a gastrostomy tube (GT). The client pours 40 mL of formula into a feeding syringe and allows the solution to flow in by gravity. When the syringe is completely empty, the client adds an additional 40 mL of the formula, followed by 50 mL of water. Which instruction should the nurse provide to the client?

Add the second portion of the feeding before the syringe is completely empty.

Use 25 mL of water between the two portions of the feeding to flush the GT.

Raise the syringe barrel higher to increase the flow rate of the bolus feeding.

Flush the tube with 50 mL of water between the two portions of the feeding.

Answer and Explanation

The Correct Answer is D

A.   This instruction is not recommended because adding the second portion of the feeding before the syringe is empty can lead to inconsistent feeding rates and potential complications, such as overloading the stomach with too much formula at once.
B.   Flushing the GT with water between portions of feeding is a good practice to prevent clogging and to ensure that all formula is delivered. However, 25 mL of water is generally not enough; standard practice typically involves using 30 to 60 mL of water for effective flushing. This option is close but not as specific as the recommended volume.
C.   Raising the syringe barrel can increase the flow rate of the feeding, but this approach should be used with caution. Rapid flow can cause gastrointestinal discomfort or cramping. The primary focus should be on ensuring proper flushing and administration rather than manipulating the flow rate in this way.
D.   This option is the best practice because flushing the GT with 50 mL of water between portions of the feeding helps to clear any remaining formula from the tube and prevents clogging. Proper flushing also helps ensure that the entire dose of formula is delivered and maintains tube patency.

Nursing Test Bank

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Correct Answer is D

Explanation

A. While the use of absorbent undergarments is relevant to managing urinary incontinence, having them dry for 6 hours indicates that they are performing their function well in terms of absorbing urine. This finding does not immediately suggest a new issue that needs urgent further assessment.
B. A heel dressing saturated with serous drainage suggests that the stage II pressure ulcer on the left heel is producing a significant amount of fluid. Serous drainage is typically clear or light yellow and can indicate a wound that is still in the inflammatory phase of healing
C. Frequent requests for sleep medication can indicate issues with sleep patterns or underlying psychological stress. While it’s important to address sleep difficulties, this finding might not be as immediately critical as other concerns but warrants further assessment to address possible underlying causes and manage sleep issues appropriately.
D. Confusion about time, place, and environment in a newly admitted client is a significant finding and requires urgent further assessment. This level of confusion could be indicative of a serious issue such as delirium, which can be caused by various factors including infection, dehydration, metabolic imbalances, or a sudden change in environment.

A. Over the cheeks. B. Around the nostrils. C. Across the forehead. D. Bridge of the nose. E. Tops of the ears.

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

Explanation

A. The cheeks can be affected by the nasal cannula, especially if it is not positioned properly or if it causes irritation over time.
B. The area around the nostrils is one of the most common sites for skin damage related to nasal cannulas. Continuous contact with the cannula can cause irritation, redness, or even sores in this area.
C. The nasal cannula itself does not typically make contact with the forehead. Therefore, skin damage across the forehead is not generally a concern related to the use of a nasal cannula.
D. The bridge of the nose is a key area to inspect for skin damage. The nasal cannula’s prongs often rest on or near the bridge of the nose, which can lead to pressure sores, redness, or irritation in this area. Regular assessment is important to prevent and address any damage.
E. The tops of the ears can be affected if the nasal cannula’s tubing or securing mechanism (such as behind-the-ear supports or loops) causes friction or pressure. Skin breakdown can occur in this area if the cannula is not properly adjusted or if it causes irritation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

Correct Answer is D

Explanation

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

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

Explanation

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.

The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?