A nurse administers 200 mL of enteral nutrition via a client’s gastrostomy (GT) tube. The nurse flushes the feed bolus with 30 mL of water before and after the feed. How many mL does the nurse document as intake in the I&O?

(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Choice A Reason:

Lubricate the suction catheter tip with sterile saline is important to ensure smooth insertion and reduce trauma to the tracheal mucosa. However, this is not the first step. Preoxygenation is crucial to prevent hypoxia during the suctioning process.

Choice B Reason:

Perform chest physiotherapy prior to suctioning can help mobilize secretions, making them easier to remove. While beneficial, it is not the immediate first step. Ensuring the client is adequately oxygenated takes precedence.

Choice C Reason:

Hyperventilate the client on 100% oxygen prior to suctioning is correct. This step is essential to prevent hypoxia during suctioning. Suctioning can temporarily reduce oxygen levels, so preoxygenating the client helps maintain adequate oxygenation throughout the procedure.

Choice D Reason:

Suction two to three times with a 60-second pause between passes is a recommended practice to allow the client to recover between suctioning attempts. However, this step follows the initial preoxygenation.

Choice A Reason:

Providing a bed bath is a task that can be delegated to unlicensed assistive personnel (UAP). This task is routine and does not require clinical judgment or advanced nursing skills. UAPs are trained to perform basic care activities such as bathing, which helps maintain the client’s hygiene and comfort.

Choice B Reason:

Assisting in toileting is another task that can be delegated to UAPs. This task involves helping clients with their toileting needs, which is within the scope of practice for UAPs. It does not require the clinical judgment or assessment skills that are reserved for licensed nurses.

Choice C Reason:

Evaluating the effectiveness of a treatment is a task that cannot be delegated to UAPs. This task requires clinical judgment and the ability to assess the client’s response to treatment, which are responsibilities of licensed nurses. Only licensed nurses have the training and expertise to evaluate treatment outcomes and make necessary adjustments.

Choice D Reason:

Assessment of a stoma is a task that cannot be delegated to UAPs. Assessing a stoma involves evaluating its appearance, function, and any signs of complications, which requires clinical judgment and expertise. This task is within the scope of practice for licensed nurses, who are trained to perform comprehensive assessments.

Choice E Reason:

Discharge teaching is a task that cannot be delegated to UAPs. Discharge teaching involves providing clients with important information about their care after leaving the healthcare facility, including medication instructions, follow-up appointments, and lifestyle modifications. This task requires clinical knowledge and the ability to educate clients effectively, which are responsibilities of licensed nurses.