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

Answer and Explanation

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.

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Correct Answer is ["A","B","D"]

Explanation

A. 1 tbsp honey: Honey is a quick source of glucose and is an appropriate choice to raise blood sugar rapidly during hypoglycemia.

B. 5 hard candies: Hard candies containing sugar can provide a quick source of glucose and are suitable for treating hypoglycemia.

C. 240 mL regular sodamight provide 20 to 30 grams of carbohydrates, which could be too much and may lead to a rebound hypoglycemia after the initial correction of blood glucose levels.

D. 120 mL unsweetened fruit juice: Unsweetened fruit juice provides a quick source of glucose, which is essential for rapidly raising blood sugar levels in a hypoglycemic patient. The sugar in the juice is readily absorbed into the bloodstream, helping to counteract the effects of low blood sugar. It's important to choose unsweetened juice to avoid a sudden spike in blood sugar followed by another drop.

E. 120 mL milk: Milk contains lactose, a natural sugar, but it also contains protein and fat, which can slow down the absorption of sugar into the bloodstream. Therefore, it may not be as effective in rapidly raising blood sugar levels during an episode of hypoglycemia.

A. Proliferation B. Inflammation C. Maturation D. Remodeling phase

Correct Answer is B

Explanation

A. Proliferation Phase:
Explanation: This phase involves the formation of new tissue to fill the wound space. It includes granulation tissue formation and wound contraction.

B. Inflammation Phase:
Explanation: This is the initial phase characterized by hemostasis and inflammation, aimed at stopping bleeding and preventing infection. Blood vessels constrict, platelets aggregate, and inflammatory cells arrive at the wound site.

C. Maturation Phase:
Explanation: Also known as the remodeling phase, it involves the remodeling and realignment of collagen fibers and the strengthening of scar tissue.

D. Remodeling Phase:
Explanation: Remodeling and maturation are often considered together as the final stage of wound healing, where collagen fibers reorganize and gain strength.

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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","B","D"]

Explanation

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Correct Answer is B

Explanation

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