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 A

Explanation

A. Pneumonia:
Dysphagia, or difficulty swallowing, can lead to aspiration, where food or liquids enter the airway and lungs instead of the stomach. This can result in pneumonia, an infection of the lungs. Clients with dysphagia are at an increased risk of developing pneumonia due to the aspiration of foreign material into the lungs.

B. Pressure Injury:
Pressure injuries (formerly known as pressure ulcers or bedsores) are caused by prolonged pressure on the skin, usually over bony prominences. Dysphagia itself is not directly related to pressure injuries. These injuries are more commonly associated with immobility and constant pressure on specific areas of the body.

C. Pulmonary Embolism:
Pulmonary embolism is a blockage of the pulmonary artery, usually by a blood clot that travels to the lungs from the legs or other parts of the body. While dysphagia is not directly associated with pulmonary embolism, conditions that cause immobility (such as being bedridden due to dysphagia) can contribute to the risk of developing blood clots.

D. Diarrhea:
Dysphagia is difficulty swallowing and is not directly related to diarrhea. Diarrhea is often associated with gastrointestinal issues, infections, or dietary factors. Monitoring for complications of dysphagia would primarily focus on respiratory issues, such as aspiration pneumonia.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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