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. Dry mucous membranes:
Explanation: Dry mucous membranes are not typically associated with hypoglycemia. Instead, they might be seen in conditions such as dehydration.
B. Fruity breath odor:
Explanation: Fruity breath odor is more commonly associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia, not hypoglycemia.
C. Diaphoresis:
Explanation: Diaphoresis, or excessive sweating, is a common manifestation of hypoglycemia. It results from the activation of the sympathetic nervous system in response to low blood sugar levels.
D. Polyuria:
Explanation: Polyuria, or increased urination, is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia and diabetes.
Correct Answer is C
Explanation
A. Metoprolol 50 mg PO daily:
This is a beta-blocker that helps lower blood pressure and heart rate. While it may be part of managing heart failure, it is not the immediate priority in a client presenting with signs of fluid overload and congestion.
B. Maintain accurate intake and output records:
Monitoring intake and output is important in managing fluid balance.
However, in this situation, the priority is to address the existing fluid overload promptly.
C. Furosemide (Lasix) 40 mg push:
Furosemide is a loop diuretic that promotes the excretion of excess fluid. Administering it "push" implies a more rapid onset of action, making it suitable for addressing acute fluid overload.
D. Encourage fluid intake, more than 2000 mL/day:
In the context of fluid overload, encouraging additional fluid intake is contraindicated. The focus should be on removing excess fluid with diuretic therapy rather than promoting more intake.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today