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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Abrasion:
This type of wound occurs when the skin rubs or scrapes against a rough surface. It's often referred to as a "scrape" and typically involves superficial damage to the skin without penetration or tearing.

B. Contusion:
Commonly known as a bruise, a contusion results from blunt trauma to the body, causing blood vessels to break and leak blood into the surrounding tissues. The skin remains intact, but there's discoloration due to the blood.

C. Laceration:
This type of wound involves a tear or irregular cut in the skin, often with jagged or rough edges. Lacerations typically result from sharp or blunt trauma that causes the skin to tear.

D. Puncture:
Puncture wounds occur when a sharp object pierces the skin and underlying tissues, creating a small, deep hole. These wounds might not bleed much externally but can cause damage to internal structures and carry a risk of infection due to the depth and possible trapping of debris.

A. Constipation B. Memory loss C. Brittle hair D. Bleeding gums

Correct Answer is A

Explanation

A. Constipation
This is correct. Inadequate dietary intake of fiber can lead to constipation. Fiber adds bulk to the stool and promotes regular bowel movements.

B. Memory loss
Memory loss is not typically associated with an inadequate dietary intake of fiber. It is more commonly related to other factors such as aging, medical conditions, or nutritional deficiencies.

C. Brittle hair
Brittle hair is not a direct result of an inadequate intake of dietary fiber. Hair health is influenced by various factors, including overall nutrition and hydration.

D. Bleeding gums
Bleeding gums are not directly linked to an inadequate intake of fiber. However, insufficient vitamin C intake, which is often found in fruits and vegetables (sources of fiber), can contribute to gum problems.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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