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 ["B"]
Explanation
Choice A rationale
A bicarbonate level of 60 mosm/kg is not a manifestation of dehydration. In fact, dehydration can lead to metabolic acidosis, which would result in a decreased bicarbonate level.
Choice B rationale
A urine specific gravity of 1.035 is a manifestation of dehydration. The kidneys concentrate the urine in an attempt to conserve water, leading to an increased specific gravity.
Choice C rationale
A blood sodium level of 50 meq/L is not a manifestation of dehydration. Dehydration can lead to hypernatremia, or an increased sodium level, due to the loss of water.
Choice D rationale
A blood creatinine level of 0.6 mg/dL is not a manifestation of dehydration. Dehydration can lead to an increase in creatinine levels due to decreased renal perfusion.
Correct Answer is D
Explanation
Choice A rationale
Aspiration is not a common complication of TPN. TPN is administered intravenously, bypassing the gastrointestinal tract, which reduces the risk of aspiration. Choice B rationale
Polyuria, or excessive urination, is not typically a direct complication of TPN. However, the fluid balance of patients on TPN should be monitored, as both overhydration and dehydration can lead to urinary changes.
Choice C rationale
Stomatitis, or inflammation of the mouth and lips, is not a common complication of TPN. Since TPN bypasses the gastrointestinal tract, it does not typically cause oral complications.
Choice D rationale
Abdominal distention can occur as a complication of TPN. This is because TPN can cause an imbalance in the gut flora, leading to gas production and bloating. Additionally, if a patient on TPN has an underlying condition that affects gut motility, they may experience abdominal distention.
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