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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bradycardia:
Low blood sugar levels can lead to bradycardia, a slower than normal heart rate.
B. Flushed skin:
Typically, low blood sugar levels might cause pallor or cool, clammy skin, rather than flushing.x
C. Decreased appetite:
Low blood sugar might result in increased hunger or a feeling of needing to eat rather than decreased appetite.
D. Tremors:
Hypoglycemia often presents with symptoms like tremors or shakiness due to the body's response to low blood sugar.
Correct Answer is B
Explanation
A. Diarrhea:
Explanation: Vomiting is more likely to be associated with dehydration than diarrhea. While vomiting and diarrhea can both lead to fluid loss, dehydration is a more immediate concern.
B. Dehydration:
Explanation: This is correct. Vomiting can lead to a significant loss of fluids, and dehydration is a potential complication. It's important to monitor the client's fluid balance, provide oral rehydration solutions or intravenous fluids as needed, and address the underlying cause of vomiting.
C. Urinary frequency:
Explanation: While dehydration can lead to decreased urine output, urinary frequency is not a typical complication of vomiting. Dehydration often results in decreased urine production.
D. Peripheral edema:
Explanation: Peripheral edema is not a direct complication of vomiting. It is more commonly associated with conditions such as heart failure or renal issues.
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