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 B, A, C, D
Explanation
Correct Answer is B
Explanation
A. BUN (Blood Urea Nitrogen):
Explanation: BUN is a measure of kidney function and hydration status. It is not typically elevated in response to a localized infection like a pressure ulcer.
B. WBC count (White Blood Cell count):
Explanation: An elevation in the WBC count is a common indicator of infection. Increased white blood cells suggest the body's immune response to an infection.
C. Potassium:
Explanation: Potassium levels are not typically used to indicate the presence of infection. Elevated potassium may be seen in conditions affecting kidney function.
D. RBC count (Red Blood Cell count):
Explanation: The RBC count is not a specific marker for infection. It is more related to issues such as anemia or oxygen-carrying capacity.
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