Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

The charge nurse is observing a newly licensed nurse provide care for a client who is receiving continuous enteral nutrition through a percutaneous endoscopic gastrostomy (PEG) tube. Which of the following actions by the newly licensed nurse indicate appropriate basic care and comfort measures? Select all that apply.

  1. Flushes the enteral tube with 30 mL of sterile water every 4 hours.Cevap
  2. B
    Lowers the head of the bed completely flat to perform a bed bath without pausing the continuous feeding pump.
  3. Maintains the client's bed elevation at a 30-degree angle or higher throughout the duration of the infusion.Cevap
  4. D
    Instructs the unlicensed assistive personnel to evaluate the skin integrity around the gastrostomy insertion site.
  5. E
    Palpates the client's abdomen for distention prior to auscultating for the presence of bowel sounds.
  6. Cleanses the skin surrounding the gastrostomy stoma daily using mild soap and warm water.Cevap

Cevap

The correct actions include flushing the tube with 30 mL of water every 4 hours, maintaining the bed elevation at 30 degrees or higher, and cleansing the stoma site daily with mild soap and water.
The correct actions align with fundamental safety and comfort standards for enteral nutrition. Flushing the tube every 4 hours ensures it remains patent and delivers necessary hydration. Keeping the head of the bed elevated at 30 degrees or higher uses gravity to prevent gastric reflux and subsequent aspiration. Daily cleansing of the stoma site with mild soap and warm water removes drainage and prevents excoriation, thereby maintaining skin integrity.

Adım Adım Çözüm

1
Evaluate each action for its impact on patient safety regarding aspiration.
Maintaining a 30-degree head-of-bed elevation is required. Leaving the feeding running while the bed is flat is dangerous.
Enteral feedings can easily reflux into the esophagus and airway if gravity is not utilized to keep contents in the stomach.
2
Assess the appropriateness of delegation to assistive personnel.
Evaluating skin integrity cannot be delegated.
Assessments require nursing judgment and must be performed by the registered nurse.
3
Determine the correct physical assessment sequence.
Palpating before auscultating is incorrect.
Touching the abdomen can stimulate bowel motility, creating inaccurate auscultation findings.
4
Identify standard maintenance and hygiene practices for PEG tubes.
Flushing every 4 hours and washing the site daily with mild soap and water are correct.
These actions prevent tube occlusion, provide hydration, and protect the peri-stomal skin from breakdown.

Anahtar Kavram

Basic Care and Comfort: Enteral Nutrition Management
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru