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NurseDive Free Nursing Practice Question
A nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?
A. Elevate the head of the bed.
Elevating the head of the bed to a semi-Fowler's or high Fowler's position helps prevent aspiration during the feeding. This position facilitates proper digestion and reduces the risk of regurgitation or reflux. It allows gravity to assist in keeping the feeding in the stomach and reduces the likelihood of complications. The other actions mentioned are also important steps in the process but should be performed after elevating the head of the bed: Measure stomach contents: This step is usually done before administering any enteral feeding to check for the presence of residual gastric contents. It helps determine if the client is tolerating previous feedings and guides adjustments in the feeding volume or rate if needed. Return gastric content into the gastrostomy tube: If there is a significant amount of gastric residual, it is recommended to return the contents into the stomach before administering the feeding. This helps ensure that the client receives the full prescribed amount of the enteral feeding. Flush the tube with water: Flushing the gastrostomy tube with water before and after the feeding helps maintain tube patency, clears any residual feeding or medication, and prevents clogging.
B. Measure stomach contents.
C. Return gastric content into the gastrostomy tube.
D. Flush the tube with water
This question is an excerpt from Nurse Dive's nursing test bank - Gastro Urinary Systems Medication Proctored Exam. Take the full exam now
Full Explanation
Elevating the head of the bed to a semi-Fowler's or high Fowler's position helps prevent aspiration during the feeding. This position facilitates proper digestion and reduces the risk of
regurgitation or reflux. It allows gravity to assist in keeping the feeding in the stomach and reduces the likelihood of complications.
The other actions mentioned are also important steps in the process but should be performed after elevating the head of the bed:
Measure stomach contents: This step is usually done before administering any enteral feeding to check for the presence of residual gastric contents. It helps determine if the client is tolerating previous feedings and guides adjustments in the feeding volume or rate if needed.
Return gastric content into the gastrostomy tube: If there is a significant amount of gastric residual, it is recommended to return the contents into the stomach before administering the feeding. This helps ensure that the client receives the full prescribed amount of the enteral feeding.
Flush the tube with water: Flushing the gastrostomy tube with water before and after the feeding helps maintain tube patency, clears any residual feeding or medication, and prevents clogging.
Similar Questions
A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?
A. Lower the height of the solution container.
B. Stop the enema and document that the client did not tolerate the procedure.
C. Encourage the client to bear down
D. Allow the client to expel some fluid before continuing
When the client experiences cramping during the enema administration, it indicates that the colon is becoming distended. By allowing the client to expel some of the fluid, the pressure in the colon is reduced, which can help alleviate the discomfort and cramping. The nurse should pause the administration of the enema and allow the client to release some fluid before continuing. The other options mentioned are not appropriate or effective actions to relieve the client's discomfort: Lowering the height of the solution container: Lowering the height of the solution container will decrease the force of the fluid flow but may not address the underlying cause of the cramping. Allowing the client to expel some fluid is a more appropriate intervention. Stopping the enema and documenting that the client did not tolerate the procedure: While it is important to monitor the client's tolerance during the procedure, abruptly stopping the enema and documenting intolerance may not be necessary if the discomfort can be relieved by allowing the client to expel some fluid. The nurse should prioritize relieving the discomfort before deciding to stop the procedure. Encouraging the client to bear down: Bearing down or pushing can increase intra-abdominal pressure and exacerbate the cramping. This action is not recommended in this situation.
Full Explanation
When the client experiences cramping during the enema administration, it indicates that the colon is becoming distended. By allowing the client to expel some of the fluid, the pressure in the colon is reduced, which can help alleviate the discomfort and cramping. The nurse should pause the administration of the enema and allow the client to release some fluid before continuing.
The other options mentioned are not appropriate or effective actions to relieve the client's discomfort:
Lowering the height of the solution container: Lowering the height of the solution container will decrease the force of the fluid flow but may not address the underlying cause of the cramping. Allowing the client to expel some fluid is a more appropriate intervention.
Stopping the enema and documenting that the client did not tolerate the procedure: While it is important to monitor the client's tolerance during the procedure, abruptly stopping the enema and documenting intolerance may not be necessary if the discomfort can be relieved by allowing the client to expel some fluid. The nurse should prioritize relieving the discomfort before deciding to stop the procedure.
Encouraging the client to bear down: Bearing down or pushing can increase intra-abdominal pressure and exacerbate the cramping. This action is not recommended in this situation.
A nurse is reinforcing teaching about cimetidine with a client who has peptic ulcer disease. Which of the following information should the nurse include in the teaching?
A. Expect breast tenderness while taking this medication,
B. Wait at least 1 hr after taking the medication before taking an antacid
When reinforcing teaching about cimetidine with a client who has peptic ulcer disease, the nurse should include the following information: "Wait at least 1 hour after taking the medication before taking an antacid.": Cimetidine is a histamine-2 receptor antagonist that reduces stomach acid production. Taking an antacid too close in time to cimetidine may decrease its effectiveness as antacids can interfere with its absorption. The nurse should advise the client to follow the healthcare provider's instructions regarding the timing and administration of cimetidine and antacids. The following statements are incorrect or not applicable: "Expect breast tenderness while taking this medication.": Breast tenderness is not a common side effect of cimetidine. If the client experiences any unusual symptoms or side effects while taking the medication, they should consult their healthcare provider for further evaluation. "Take this medication on an empty stomach.": To reduce stomach upset, this medication should be taken with food or milk "Take ibuprofen for occasional aches and pains.": Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal complications, including ulcers. In individuals with peptic ulcer disease, it is generally recommended to avoid NSAIDs unless specifically prescribed by a healthcare provider. The nurse should emphasize the importance of discussing any pain management strategies or medications with the healthcare provider before use.
C. Take ibuprofen for occasional aches and pains
D. Take this medication on an empty stomach
Full Explanation
When reinforcing teaching about cimetidine with a client who has peptic ulcer disease, the nurse should include the following information:
"Wait at least 1 hour after taking the medication before taking an antacid.": Cimetidine is a histamine-2 receptor antagonist that reduces stomach acid production. Taking an antacid too close in time to cimetidine may decrease its effectiveness as antacids can interfere with its absorption. The nurse should advise the client to follow the healthcare provider's instructions regarding the timing and administration of cimetidine and antacids.
The following statements are incorrect or not applicable:
"Expect breast tenderness while taking this medication.": Breast tenderness is not a common side effect of cimetidine. If the client experiences any unusual symptoms or side effects while taking the medication, they should consult their healthcare provider for further evaluation.
"Take this medication on an empty stomach.": To reduce stomach upset, this medication should be taken with food or milk
"Take ibuprofen for occasional aches and pains.": Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal complications, including ulcers. In individuals with peptic ulcer disease, it is generally recommended to avoid NSAIDs unless specifically prescribed by a healthcare provider. The nurse should emphasize the importance of discussing any pain management strategies or medications with the healthcare provider before use.
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse identify as a risk factor for this condition?
A. History of bulimia
B. Consumes spicy foods 5 to 8 times weekly
C. History of ibuprofen use
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of developing peptic ulcers. It can cause irritation and damage to the lining of the stomach and small intestine, leading to the formation of ulcers. The other options may not directly contribute to the development of peptic ulcers: History of bulimia: While repeated vomiting can irritate the esophagus, it is less likely to directly cause peptic ulcers. Consuming spicy foods 5 to 8 times weekly: Spicy foods can exacerbate the symptoms of existing peptic ulcers, but they are not considered a direct risk factor for their development. Drinking green tea: Green tea is generally considered to have health benefits and is not known to be a risk factor for peptic ulcers.
D. Drinks green tea
Full Explanation
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of developing peptic ulcers. It can cause irritation and damage to the lining of the stomach and small intestine, leading to the formation of ulcers.
The other options may not directly contribute to the development of peptic ulcers:
History of bulimia: While repeated vomiting can irritate the esophagus, it is less likely to directly cause peptic ulcers.
Consuming spicy foods 5 to 8 times weekly: Spicy foods can exacerbate the symptoms of existing peptic ulcers, but they are not considered a direct risk factor for their development.
Drinking green tea: Green tea is generally considered to have health benefits and is not known to be a risk factor for peptic ulcers.