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. 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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. BUN (Blood Urea Nitrogen):
Explanation: BUN is a measure of kidney function and hydration status. It is not typically elevated in response to a localized infection like a pressure ulcer.
B. WBC count (White Blood Cell count):
Explanation: An elevation in the WBC count is a common indicator of infection. Increased white blood cells suggest the body's immune response to an infection.
C. Potassium:
Explanation: Potassium levels are not typically used to indicate the presence of infection. Elevated potassium may be seen in conditions affecting kidney function.
D. RBC count (Red Blood Cell count):
Explanation: The RBC count is not a specific marker for infection. It is more related to issues such as anemia or oxygen-carrying capacity.
Correct Answer is A
Explanation
A. Proteinuria:
Minimal change nephrotic syndrome is characterized by increased permeability of the glomerular filtration barrier, leading to proteinuria. The loss of proteins, especially albumin, in the urine is a key feature.
B. Hypocalcemia:
Hypocalcemia is not typically associated with MCNS. In fact, the loss of proteins, including albumin, in the urine can lead to decreased oncotic pressure in the blood vessels, resulting in edema. However, calcium levels are usually within the normal range.
C. Hyperalbuminemia:
This is not a characteristic finding in minimal change nephrotic syndrome. In fact, the condition is associated with hypoalbuminemia due to the loss of albumin in the urine.
D. Positive for Ketones:
Ketones are not typically associated with minimal change nephrotic syndrome. Ketones in the urine are more commonly associated with conditions like diabetic ketoacidosis or starvation.
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