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.
The Correct Answer is D
Correct answer: D
A. Cleanse the top of the can of formula with an alcohol wipe:
Explanation: It's not necessary to cleanse the top of the can of formula with an alcohol wipe. Instead, the focus should be on maintaining the cleanliness of the equipment directly involved in the administration, such as the syringe or feeding bag.
B. Keep the formula cold until instillation:
Explanation: Formula is typically administered at room temperature or body temperature. Cold formula can cause discomfort to the client and may affect the absorption of nutrients.
C. Withhold the feeding if the residual volume is 150 mL:
Explanation: The decision to withhold or proceed with the feeding based on residual volume can vary. It's essential to follow the healthcare provider's orders and facility protocols. Some facilities may have specific guidelines on when to withhold a feeding based on residual volume.
D. Flush the tube with 30 mL of sterile water before the feeding:
Explanation: Flushing the tube with sterile water before the feeding is a standard practice to ensure the tube is clear and patent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. The patient uses crutches with a swing-to gait.
This action doesn't necessarily indicate a concern after hip arthroplasty. However, the nurse might want to assess the patient's gait and the use of crutches to ensure the proper technique is being employed and that the patient feels comfortable and stable.
B. The patient sits straight up on the edge of the bed.
Sitting straight up on the edge of the bed may not be suitable immediately after hip arthroplasty, especially with the posterior approach. The nurse should assess the patient's ability to sit upright without putting excessive pressure or strain on the surgical site.
C. The patient bends over the sink while brushing teeth.
Bending over can put stress on the surgical site and should be avoided during the initial recovery period after hip arthroplasty. This action might strain the incision and affect the healing process.
D. The patient leans over to pull on shoes and socks.
Similar to bending over the sink, leaning over to put on shoes and socks can strain the hip joint and surgical site. This movement could potentially put stress on the incision and hinder the healing process.
Correct Answer is A
Explanation
A. Flush the tube with water:
This is the correct action to take first. Flushing the tube with water ensures that the tube is clear and functional before administering the bolus enteral feeding.
B. Measure stomach contents:
This is not the first action to take. Before measuring stomach contents, it's important to confirm that the tube is patent and clear by flushing it with water.
C. Elevate the head of the bed:
While elevating the head of the bed is important during and after enteral feedings to reduce the risk of aspiration, it is not the first step. The initial focus should be on verifying the tube's patency.
D. Return gastric content into the gastrostomy tube:
If there is resistance or difficulty flushing the tube, returning gastric contents into the tube may be necessary, but it's not the first action. The first step is to attempt to clear the tube with water.
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