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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "My appetite will be decreased."
Explanation: Hyperglycemia is often associated with increased appetite rather than decreased appetite.

B. "I might experience blurry vision at times."
Explanation: This is correct. Blurry vision can be a symptom of hyperglycemia due to changes in the fluid levels in the eye caused by high blood sugar.

C. "My breath may have a fruity odor."
Explanation: Fruity breath odor is associated with diabetic ketoacidosis (DKA), which is a severe complication of diabetes. It occurs due to the production of ketones during uncontrolled diabetes, leading to this distinct odor. While it's related to high blood sugar, it's more specifically linked to DKA.

D. "I will be more thirsty than usual."
Explanation: Increased thirst is a classic symptom of hyperglycemia. When blood sugar levels are high, the body tries to flush out the excess sugar through increased urination, leading to dehydration and subsequently increased thirst.

A. "I will allow the position my mother finds most comfortable during the feeding." B. "I will turn my mother on her left side during the feeding." C. "I will position the head of the bed 45 degrees during the feeding." D. "I will elevate the head of the bed 10 degrees during the feeding."

Correct Answer is C

Explanation

A. "I will allow the position my mother finds most comfortable during the feeding."
This statement does not provide specific guidance on the proper positioning for enteral feedings. It's important to follow recommended positions to prevent complications.

B. "I will turn my mother on her left side during the feeding."
Turning the client on the left side is not a recommended position for enteral feedings. The head of the bed is usually elevated to 30-45 degrees to prevent aspiration.

C. "I will position the head of the bed 45 degrees during the feeding."
This is the correct choice. Elevating the head of the bed to 45 degrees helps prevent aspiration and facilitates proper flow of enteral feedings into the stomach.

D. "I will elevate the head of the bed 10 degrees during the feeding."
While some elevation is better than lying flat, the recommended angle is usually 30-45 degrees to minimize the risk of regurgitation and aspiration.

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A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?

Correct Answer is C

Explanation

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