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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.
Choice B rationale
Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.
Choice C rationale
Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.
Choice D rationale
Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
An increased blood osmolarity, such as 260 mOsm/kg, can be a sign of dehydration. When the body is dehydrated, the concentration of solutes in the blood can increase, leading to higher osmolarity.
Choice B rationale
Hypotension, or low blood pressure, is not typically a sign of dehydration. In fact, dehydration can often cause blood pressure to increase due to the body’s efforts to compensate for the lack of fluid.
Choice C rationale
A high urine specific gravity, such as 1.035, can indicate dehydration. This measurement reflects the concentration of solutes in the urine, and a high value can mean that the body is conserving water due to dehydration.
Choice D rationale
An elevated blood sodium level, such as 150 mEq/L, can be a sign of dehydration. When the body is dehydrated, the concentration of sodium in the blood can increase.
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