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.
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reposition the client every 2hr:
Regular repositioning helps redistribute pressure and prevent tissue damage. Turning the client every 2 hours is even better, especially for those at higher risk.
B. Elevate the head of the client's bed 45°:
Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.
C. Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.
D. Provide the client with a high-calorie diet:
While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.
Correct Answer is D
Explanation
A. 8.0: An aspirate pH of 8.0 would indicate an alkaline substance. This would not be typical of stomach contents, which are acidic. An alkaline pH might suggest placement in the intestines or respiratory tract.
B. 6.0: While this is less alkaline than 8.0, it is still not within the typical range for stomach contents. Stomach aspirate is generally more acidic.
C. 7.0: A pH of 7.0 is neutral. Stomach contents are typically more acidic, so a neutral pH would not be consistent with correct NG tube placement in the stomach.
D. 4.0: This is within the acidic range and is consistent with the pH of stomach contents. It would be considered an indication of correct NG tube placement in the stomach.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.