The nurse observes a student nurse administer 100 mg phenytoin (Dilantin) suspension and 20 mg famotidine (Pepcid) solution through a gastrostomy tube. The client receives an enteral feeding through the gastrostomy tube at a rate of 75 mL/h. Which action by the student nurse requires an IMMEDIATE intervention by the nurse?

Choice A reason: Checking the drainage bag level ensures it’s below the abdomen to promote gravity-dependent outflow. This addresses reduced outflow in peritoneal dialysis, making it a correct action the nurse would take to resolve the inflow-outflow discrepancy safely.

Choice B reason: Repositioning to the side can dislodge catheter obstructions or improve drainage in peritoneal dialysis. This is a standard intervention for low outflow, making it a correct action the nurse would perform to correct the client’s dialysis flow issue.

Choice C reason: Good body alignment prevents catheter kinking and promotes effective drainage in peritoneal dialysis. This addresses outflow issues, making it a correct action the nurse would take to ensure proper function of the dialysis system for the client.

Choice D reason: Checking for kinks in the dialysis system identifies mechanical causes of reduced outflow. This is a key troubleshooting step, making it a correct action the nurse would perform to resolve the inflow-outflow imbalance in the client’s peritoneal dialysis.

Choice E reason: Contacting the provider is premature before troubleshooting mechanical issues like kinks or positioning. Checking the drainage bag is a priority, making this incorrect, as it delays the nurse’s initial actions to correct the dialysis outflow problem independently.

Choice F reason: Increasing the flow rate doesn’t address outflow obstruction and may worsen fluid imbalance. Repositioning is more appropriate, making this incorrect, as it’s not a safe action compared to the nurse’s focus on resolving mechanical dialysis issues first.

Choice A reason: Clamping the T-tube risks bile backup and infection, especially with 750 mL drainage. Notifying the surgeon addresses potential complications, making this incorrect, as it’s unsafe compared to the nurse’s priority of reporting excessive T-tube output.

Choice B reason: Irrigating the T-tube without medical orders risks dislodging it or causing infection. Notifying the surgeon is appropriate for 750 mL drainage, making this incorrect, as it’s risky compared to the nurse’s action to seek medical evaluation.

Choice C reason: Notifying the surgeon is most appropriate, as 750 mL of T-tube drainage may indicate a complication like bile leak or obstruction. This aligns with post-surgical care protocols, making it the correct intervention for the nurse to address excessive drainage.

Choice D reason: Documenting is necessary but doesn’t address the potential complication of 750 mL drainage. Notifying the surgeon is urgent, making this incorrect, as it delays the nurse’s priority of reporting a significant post-surgical T-tube output to the surgeon.