A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
The nurse administers the feeding through a syringe barrel by gravity.
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 initiates the feeding after aspirating 50 mL of gastric residual.
The Correct Answer is B
A. The nurse administers the feeding through a syringe barrel by gravity.
This is an appropriate method for administering intermittent tube feedings. Gravity feeding with a syringe allows for controlled delivery of the feeding solution.
B. The nurse allows the client to rest in a supine position during feeding.
Feeding a client in a supine position is generally acceptable, especially if the client is comfortable and doesn't experience complications. However, if there are specific contraindications or concerns for aspiration, the nurse should follow the prescribed position guidelines.
C. The nurse irrigates the NG tube with tap water after feeding.
Using tap water to irrigate an NG tube is not recommended, as it may lead to complications such as electrolyte imbalances. Sterile or distilled water should be used for irrigation.
D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
This is an appropriate action. Aspirating gastric residual before initiating a feeding helps assess the presence of gastric contents, ensuring that the client is ready to receive the feeding. However, specific institutional policies may dictate the threshold for gastric residual volume that requires intervention.
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Related Questions
Correct Answer is C
Explanation
A. To confirm the placement of the NG tube:
Confirming NG tube placement is typically done using other methods, such as auscultation of air insufflation, pH testing, or X-ray. Gastric residual measurement helps assess the status of the stomach content but is not the primary method for confirming tube placement.
B. To determine the client's electrolyte balance:
While the gastric contents do contain electrolytes, the primary purpose of measuring gastric residual is to assess gastric emptying and potential feeding intolerance. It is not the most accurate method for determining overall electrolyte balance.
C. To identify delayed gastric emptying:
This is the correct and primary purpose. Measuring gastric residual helps in identifying if there's a delay in the stomach emptying the previously administered feeding, which can inform the nurse about the client's tolerance to enteral nutrition.
D. To remove gastric acid that might cause dyspepsia:
The process of measuring gastric residual doesn't involve removing gastric acid. It's more about assessing how much of the previously administered feeding remains in the stomach. If there's a high residual volume, it may suggest delayed emptying or feeding intolerance. The focus is on adjusting the feeding plan rather than removing gastric acid.
Correct Answer is C
Explanation
A. Explain alternatives to the procedure to the client.
The nurse should provide information about alternative treatments or procedures available to the client, ensuring they have a comprehensive understanding of their options.
B. Discuss the risks of the procedure with the client.
It is crucial for the nurse to communicate the potential risks and complications associated with the procedure to the client, allowing them to make an informed decision.
C. Confirm that the client is competent to sign for the procedure.
Before obtaining informed consent, the nurse should ensure that the client has the mental capacity to understand the information provided, make decisions, and provide consent.
D. Inform the client about what will occur during the procedure.
The nurse should educate the client about the details of the procedure, including what to expect before, during, and after. This information aids in the client's understanding and decision-making process.
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