A charge nurse is observing a nurse administer intermittent tube feedings via an NG tube to a client.
Which of the following actions by the nurse should prompt the charge nurse to intervene?
The nurse allows the client to rest in a supine position during feeding.
The nurse irrigates the NG tube with tap water after feeding.
The nurse administers the feeding through a syringe barrel by gravity.
The nurse initiates the feeding after aspirating 50 ml of gastric residual.
The nurse initiates the feeding after aspirating 50 ml of gastric residual.
The Correct Answer is A
Choice A rationale
Allowing the client to rest in a supine position during feeding should prompt the charge nurse to intervene. The client should be in an upright position during feedings and for an hour afterwards to prevent aspiration.
Choice B rationale
Irrigating the NG tube with tap water after feeding is a standard practice. This helps to keep the tube patent and prevent blockages.
Choice C rationale
Administering the feeding through a syringe barrel by gravity is a common method for giving intermittent tube feedings. This method allows for controlled administration of the feeding.
Choice D rationale
Initiating the feeding after aspirating 50 ml of gastric residual is a standard practice. Checking gastric residual volume before feedings helps to assess gastric emptying and tolerance to the feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placing clean linen that touched the floor in the soiled linen bag is a correct practice. This is because the floor is considered dirty, and any linen that comes into contact with it should be considered contaminated.
Choice B rationale
Shaking soiled linen to remove any toilet paper remnants is not a correct practice. Shaking soiled linen can disperse pathogens into the air, increasing the risk of disease transmission.
Choice C rationale
Placing the soiled linen on the floor before bagging it is not a correct practice. Soiled linen should be handled as little as possible and placed directly into a designated, leak-proof container.
Choice D rationale
Holding the soiled linen against her body while carrying it to the linen bag is not a correct practice. Soiled linen should be handled carefully to avoid contact with the body, as this can lead to contamination of the worker’s clothing and potentially spread infection.
Correct Answer is C
Explanation
Choice A rationale
Irrigating the nasogastric tube with tap water is not recommended. Tap water is not sterile and can introduce bacteria into the stomach, potentially causing infection.
Choice B rationale
Marking abdominal girth once daily is not sufficient for a client who is postoperative following peritoneal lavage for peritonitis. This client is at risk for complications such as abscess formation and bowel obstruction, which can cause rapid changes in abdominal girth. Therefore, abdominal girth should be measured more frequently.
Choice C rationale
Placing the client in a high Fowler’s position is the correct intervention. This position, which involves the client sitting up at an angle of 45 to 60 degrees, can help reduce pressure on the abdominal area, promote better lung expansion, and facilitate drainage of gastric contents, thus reducing the risk of aspiration.
Choice D rationale
Ambulating the client twice daily is not appropriate in this case. The client has just undergone a major abdominal surgery and has a nasogastric tube and closed-suction drains in place. Early ambulation may not be feasible due to the risk of dislodging the drains or causing pain and discomfort.
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