The nurse is caring for a patient with a jejunostomy tube. Which statement by the nurse indicates the need for additional information to safely manage the medical intervention?
1. "I will keep the patient on bed rest until the tube can be removed.".
2. "It's my habit to irrigate the jejunostomy tube just prior to administering the patient's sleeping medication."
3. "A pH of 5 or less indicates the tube is in the stomach, not the intestine.".
4. "I plan to assess the patient's abdomen for distention at regular intervals.".
1
Rationale 1: There is no indication that the patient should remain on bed rest.
Rationale 2: The tube should be irrigated prior to each medication administration and as ordered.
Rationale 3: A pH of 5 or less indicates gastric placement, while a pH or 7 or more indicates intestinal placement.
Rationale 4: If the patient is not tolerating feedings, abdominal distention may occur.
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