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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
This is a correct action. Cleaning the wound with a sterile solution, such as 0.9% sodium chloride, helps minimize contamination and ensures a more accurate culture.

B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
Using antiseptics directly on the wound before obtaining a specimen can interfere with the culture results. It's essential to use a non-bacteriostatic solution for cleaning.

C. Include intact skin at the wound edges in the culture.
The culture should focus on the material within the wound itself rather than including intact skin. The goal is to identify the specific pathogens causing the infection.

D. Swab an area of skin away from the wound to identify normal flora.
The specimen should be taken directly from the wound site to identify the pathogens responsible for the infection. Swabbing away from the wound won't provide relevant information.

A. Hypertension B. Peripheral edema C. Oliguria D. Bradycardia

Correct Answer is C

Explanation

A. Hypertension:
Hypovolemia is characterized by a decrease in blood volume. This reduction in blood volume usually leads to decreased blood pressure, not hypertension.

B. Peripheral edema:
Edema is more commonly associated with hypervolemia (excess fluid volume) rather than hypovolemia. In hypovolemia, the body is experiencing a deficit of fluids, and edema is not a typical manifestation.

C. Oliguria:
This is the correct answer. Oliguria, or reduced urine output, is a common finding in hypovolemia. When the body is low on fluids, the kidneys try to conserve water by decreasing urine production.

D. Bradycardia:
Hypovolemia often leads to tachycardia (an increased heart rate) as the body attempts to compensate for the decreased blood volume by pumping the existing blood more quickly. Bradycardia is not a typical finding in hypovolemia.

View Question and Answer

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

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 caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

Correct Answer is A

Explanation

A nurse is collecting data on a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data represents an adverse outcome (side effect) of this infusion?

A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching about informed consent with a newly licensed nurse. Which of the following should be included as a responsibility of the nurse in this process?

A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and having blurred vision. The client's blood glucose level is 48 mg/dL. Which of the following foods should the nurse give to the client? (Select all that apply).

A nurse is assisting with teaching a class of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse include?