A nurse is preparing an intervention plan for a client who is receiving tube feedings after an oral surgery. Which of the following measures can prevent improper infusion and assist in preventing vomiting?

Correct Answer: D

Rationale: The correct answer is D: Checking the tube placement and gastric residual prior to feedings. This is crucial to ensure proper placement of the tube and to assess if there is any undigested food in the stomach, which can lead to vomiting if fed through the tube. By checking these factors before administering feedings, the nurse can prevent complications. A: Consulting the physician and dietitian is important but does not directly prevent improper infusion or vomiting. B: Administering feedings at room temperature is a good practice but does not directly prevent vomiting. C: Changing the tube feeding container and tubing may be necessary for hygiene but does not directly prevent improper infusion or vomiting. In summary, checking the tube placement and gastric residual is essential in preventing vomiting and ensuring proper feeding, making it the correct choice.

Correct Answer: C

Rationale: The correct answer is C: Elevated serum ammonia levels. Prolonged antibiotic therapy can lead to disruption of normal gut flora, causing overgrowth of ammonia-producing bacteria. Elevated serum ammonia levels can indicate hepatic encephalopathy, a serious condition that requires immediate intervention. Coagulation problems (A) are more commonly associated with liver disease or vitamin deficiencies. Impaired absorption of amino acids (B) is typically seen in conditions like celiac disease or gastrointestinal disorders, not specifically related to prolonged antibiotic use. Increased mucus and bicarbonate secretion (D) are not directly related to prolonged antibiotic therapy, but rather to respiratory or gastrointestinal conditions.

Correct Answer: A

Rationale: The correct answer is A: Prevention of aspiration. This is essential in tube feeding to avoid the risk of food or liquid entering the lungs, causing aspiration pneumonia. Nursing interventions for this include ensuring proper positioning during and after feeding, checking residual volumes before each feeding, and using the appropriate tube size and placement. Incorrect Choices: B: Prevention of diarrhea - Diarrhea is not directly related to tube feeding complications, but rather to factors such as infection, medication side effects, or underlying conditions. C: Maintenance of tube patency - While important, this focuses on ensuring the tube remains clear and functional, not directly related to preventing aspiration. D: Maintenance of tube placement - Ensuring proper tube placement is crucial for effective feeding but does not directly address the risk of aspiration.

Correct Answer: A

Rationale: Step 1: The priority is to administer fluids to rehydrate the patient. Step 2: Intravenous fluids are not mentioned, so the nurse should start with oral fluids. Step 3: Option A is the most appropriate choice as it addresses the need for fluid intake to promote rehydration. Step 4: Water (Option B) lacks electrolytes that aid in rehydration. Step 5: Hot tea (Option C) may irritate the stomach and not provide adequate hydration. Step 6: Gatorade (Option D) contains electrolytes but may be too heavy for initial rehydration.

Correct Answer: C

Rationale: The correct answer is C: Projectile vomiting of undigested food. In a patient with a perforated peptic ulcer, the sudden opening in the stomach lining allows food to pass into the abdominal cavity, leading to projectile vomiting of undigested food. This symptom is a classic sign of a perforation and requires immediate medical attention. Choice A is incorrect because vomiting of bright-red blood is more indicative of upper gastrointestinal bleeding, not a perforation. Choice B is incorrect as vomiting undigested food is more common in conditions like gastroparesis, not perforated ulcers. Choice D is incorrect as severe upper abdominal pain and back pain are symptoms of a perforation but not as specific as projectile vomiting of undigested food.