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?

Assist the client to low Fowler's position.

Warm the feeding solution to body temperature.

Discard any residual gastric contents.

Test the pH of gastric aspirate.

Answer and Explanation

The Correct Answer is D

A. Assist the client to low Fowler's position:
Placing the client in a semi-upright or low Fowler's position during and after the feeding helps prevent aspiration and facilitates digestion. This position reduces the risk of regurgitation and reflux.

B. Warm the feeding solution to body temperature:
Ensuring the feeding solution is at room temperature or slightly warmer can enhance the client's comfort and reduce the risk of cramping or discomfort caused by cold fluids.

C. Discard any residual gastric contents:
Before initiating a new feeding, it's essential to check and discard any residual gastric contents from the previous feeding to prevent contamination, ensure accurate measurement, and minimize the risk of bacterial growth.

D. Test the pH of gastric aspirate:
Checking the pH of gastric aspirate is an important step to confirm the proper placement of the NG tube in the stomach. Gastric pH is typically acidic (pH less than 5), indicating the correct placement of the tube in the stomach rather than the respiratory tract, where the pH is higher (more alkaline).

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Correct Answer is C

Explanation

A. Height of the IV pole:
Explanation: The height of the IV pole is important for controlling the rate of the TPN infusion. Adjusting the height can regulate the flow rate.

B. IV insertion site:
Explanation: Monitoring the IV insertion site is crucial to assess for signs of infection, inflammation, or infiltration, which can compromise the effectiveness of TPN.

C. Manifestations of hypoglycemia:
Explanation: TPN often contains glucose, and monitoring for signs of hypoglycemia is important, as abrupt cessation of TPN can lead to low blood glucose levels.

D. The client's oral intake:
Explanation: Since the client is receiving TPN, their oral intake is not the primary source of nutrition. TPN provides essential nutrients intravenously.

A. The nurse administers the feeding through a syringe barrel by gravity. B. The nurse allows the client to rest in a supine position during feeding. C. The nurse irrigates the NG tube with tap water after feeding. D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.

Correct Answer is B

Explanation

A. The nurse administers the feeding through a syringe barrel by gravity.
This is an appropriate method for administering intermittent tube feedings. Gravity feeding with a syringe allows for controlled delivery of the feeding solution.

B. The nurse allows the client to rest in a supine position during feeding.
Feeding a client in a supine position is generally acceptable, especially if the client is comfortable and doesn't experience complications. However, if there are specific contraindications or concerns for aspiration, the nurse should follow the prescribed position guidelines.

C. The nurse irrigates the NG tube with tap water after feeding.
Using tap water to irrigate an NG tube is not recommended, as it may lead to complications such as electrolyte imbalances. Sterile or distilled water should be used for irrigation.

D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
This is an appropriate action. Aspirating gastric residual before initiating a feeding helps assess the presence of gastric contents, ensuring that the client is ready to receive the feeding. However, specific institutional policies may dictate the threshold for gastric residual volume that requires intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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