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.
None
None
The Correct Answer is A
Correct answer: D
A. Wiping the top of the can before opening prevents contamination and reduces the risk of introducing pathogens into the feeding system.
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. In most cases, flushing is done with tap water (if safe for drinking) or sterile water in immunocompromised clients. The key step is to flush before and after feedings, but the standard practice is not automatically sterile water for all patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Vitamin A:
Solubility: Fat-soluble, not water-soluble.
Explanation: Vitamin A is a fat-soluble vitamin.
B. Vitamin C:
Solubility: Water-soluble.
Explanation: Vitamin C is water-soluble and plays a crucial role in collagen synthesis, immune function, and antioxidant activity.
C. Vitamin E:
Solubility: Fat-soluble, not water-soluble.
Explanation: Vitamin E is a fat-soluble vitamin with antioxidant properties.
D. Vitamin D:
Solubility: Fat-soluble, not water-soluble.
Explanation: Vitamin D is a fat-soluble vitamin that plays a key role in calcium absorption and bone health.
Correct Answer is C
Explanation
A. Apply Neosporin to avoid infection:
This choice suggests applying Neosporin to the surgical site. However, the immediate postoperative care for cleft lip surgery often involves keeping the incision site covered with sterile dressings. Topical antibiotics may be prescribed by the healthcare provider if deemed necessary, but it's not a routine application without specific instructions.
B. Apply elbow immobilizers when not being held:
This choice implies using elbow immobilizers for the child. However, elbow immobilizers are not a standard intervention for cleft lip surgery. The focus is usually on keeping the surgical site clean and preventing complications like infection.
C. Suction secretions away from the suture line:
This is the recommended choice. Suctioning helps maintain a clear airway and prevents secretions from affecting the surgical site. It's a crucial step in the immediate postoperative period.
D. Feed increased amounts of formula to prevent weight loss:
While feeding is an essential aspect of care, especially for nutritional support, the immediate concern in the first few days after cleft lip surgery is often related to maintaining a patent airway and preventing infection. Feeding interventions might be guided by the healthcare provider's recommendations, but it's not the primary focus in the initial postoperative period.
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