Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

A nurse is preparing to administer an intermittent bolus enteral feeding via a percutaneous endoscopic gastrostomy (PEG) tube to a client. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

  1. 1Elevate the head of the bed to at least 30 to 45 degrees.
  2. 2Aspirate stomach contents to measure the gastric residual volume.
  3. 3Flush the gastrostomy tube with 30 mL of water.
  4. 4Allow the prescribed enteral formula to flow in by gravity.
  5. 5Flush the tube with 30 mL of water and clamp the device.

Cevap

The correct sequence is: Elevate the head of the bed, measure the gastric residual volume, flush the tube with water, administer the enteral formula by gravity, and finally flush the tube again before clamping.
Safe administration of enteral feedings follows a strict chronological order that prioritizes airway protection first (elevating the head of the bed), followed by assessing tolerance (checking residual volume), ensuring tube patency (pre-flush), delivering nutrition safely (gravity feeding), and maintaining equipment integrity (post-flush and clamp).

Adım Adım Çözüm

1
Elevate the head of the bed to at least 30 to 45 degrees.
The client is placed in a safe, upright position.
Elevating the head of the bed is the most critical initial step to protect the airway and prevent aspiration of stomach contents into the lungs during the procedure.
2
Aspirate stomach contents to measure the gastric residual volume.
The amount of undigested formula in the stomach is quantified.
Measuring the residual volume assesses gastric emptying and tolerance of previous feedings, ensuring it is safe to administer the next bolus.
3
Flush the gastrostomy tube with 30 mL of water.
The tube is cleared of gastric contents.
Flushing verifies the patency of the tube and prevents occlusion before the thick enteral formula is introduced.
4
Allow the prescribed enteral formula to flow in by gravity.
The client receives the prescribed nutrition.
Administering the feeding by gravity simulates normal filling of the stomach, preventing nausea, cramping, and vomiting.
5
Flush the tube with 30 mL of water and clamp the device.
The tube is cleared of formula and safely secured.
A final flush removes residual formula that could curdle and occlude the tube over time, and clamping prevents leakage or air entry.

Anahtar Kavram

Enteral Nutrition Administration and Aspiration Prevention
Tahmini Süre:1m 30s
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Konular

Basic Care and Comfort

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