Examkin

Question

Difficulty: MediumBasic Care and Comfort

A nurse is preparing to administer a scheduled bolus enteral feeding via a percutaneous endoscopic gastrostomy (PEG) tube to a client who is receiving long-term nutritional support. Arrange the following nursing actions in the correct sequence.

  1. 1Elevate the head of the client's bed to at least 30 to 45 degrees.
  2. 2Verify tube placement by checking the external bumper marking at the stoma site.
  3. 3Aspirate to check the gastric residual volume and return the contents to the stomach.
  4. 4Flush the gastrostomy tube with 30 mL of water.
  5. 5Administer the prescribed bolus feeding formula by gravity.

Answer

The correct sequence is to first elevate the head of the bed, then verify tube placement, check the gastric residual volume, flush the tube to ensure patency, and finally administer the feeding formula.
Safe enteral feeding administration follows a logical, safety-oriented progression. Elevating the head of the bed is the critical first step to protect the airway and prevent aspiration. Once the client is positioned safely, verifying placement ensures the tube is properly located in the stomach. Checking residual volume then assesses the client's physiological tolerance of the feeding. Flushing the tube ensures it is patent and clear. Finally, administering the formula is the last step, performed only after all safety parameters have been established.

Step-by-Step Solution

1
Elevate the head of the client's bed to at least 30 to 45 degrees.
The client is placed in a safe position to prevent aspiration.
Airway protection is the absolute priority. Manipulating the tube or feeding a flat client significantly increases the risk of aspiration pneumonia.
2
Verify tube placement by checking the external bumper marking at the stoma site.
The nurse confirms the tube has not migrated.
Ensuring correct tube placement prevents the accidental administration of formula into the peritoneal cavity or respiratory tract.
3
Aspirate to check the gastric residual volume and return the contents to the stomach.
The nurse assesses gastric emptying and prevents electrolyte loss.
High residual volumes indicate delayed gastric emptying. Returning the aspirate prevents acid-base and electrolyte imbalances.
4
Flush the gastrostomy tube with 30 mL of water.
The tube is cleared and patency is confirmed.
Flushing prevents tube clogging and ensures the pathway is clear before introducing the viscous feeding formula.
5
Administer the prescribed bolus feeding formula by gravity.
The client receives the prescribed nutrition.
Formula is administered only after safety checks (positioning, placement, tolerance, and patency) have been completed.

Key Concept

Safe administration of enteral tube feedings requires a sequential approach prioritizing aspiration prevention, verifying placement, assessing gastrointestinal tolerance, and maintaining tube patency.
Rate this question

Topics

Basic Care and Comfort

More questions from this topic