A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?
Cleanse the top of the can of formula with an alcohol wipe.
Keep the formula cold until instillation.
Withhold the feeding if the residual volume is 150 mL.
Flush the tube with 30 mL of sterile water before the feeding.
The Correct Answer is D
Correct answer: D
A. While it is important to ensure the can of formula is clean, it should be wiped with soap and water or a disinfectant wipe, not an alcohol wipe.
B. Cold formula can cause gastric discomfort or cramping. It's recommended to bring the formula to room temperature before administration to avoid gastric irritation and enhance comfort during feeding.
C. The action of withholding the feeding depends on the institution's protocol and the specific clinical condition of the client. Typically, residuals greater than 200 mL might indicate delayed gastric emptying, but the threshold can vary. A residual volume of 150 mL may not necessarily require withholding the feeding, though it may warrant further assessment.
D. It is standard practice to flush the NG tube with 30 mL of sterile water (or as per facility guidelines) before administering an enteral feeding. This helps ensure the tube is patent, reduces the risk of clogging, and ensures the feeding formula flows smoothly. Flushing before the feeding also helps clear the tube of any residual formula, preventing cross-contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Moist skin: Dehydration often leads to dry skin rather than moist skin. When the body is dehydrated, it conserves water, and one of the signs can be dry, less elastic skin.
B. High blood pressure: Dehydration tends to result in lower blood volume, which can lead to lower blood pressure rather than high blood pressure. However, severe dehydration may cause a drop in blood pressure.
C. Dark-colored urine: Dehydration commonly causes urine to become more concentrated, leading to darker urine. This is due to the kidneys conserving water and producing less urine.
D. Distended neck veins: Dehydration is more likely to result in decreased blood volume and lower venous return, which would not typically lead to distended neck veins. Distended neck veins are more commonly associated with conditions like heart failure.
Correct Answer is D
Explanation
A. Intact skin with localized erythema:
Explanation: This description is more consistent with a stage 1 pressure injury, where there is non-blanchable erythema.
B. Full thickness skin loss with visible bone:
Explanation: This description is more consistent with a stage 4 pressure injury, which involves extensive tissue loss, including exposure of bone.
C. Full thickness skin loss with visible adipose tissue:
Explanation: This finding is characteristic of a stage 3 pressure injury, where the loss of tissue extends down to the subcutaneous layer.
D. Partial-thickness skin loss with red tissue in the wound bed:
Explanation: This description is consistent with a stage 2 pressure injury, where there is partial-thickness skin loss involving the epidermis and possibly the dermis, forming a shallow open ulcer with a red-pink wound bed.
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