A nurse is caring for a client who is receiving continuous feedings via NG tube. Which of the following actions should the nurse take?
Irrigate the client's tube with 10 ml of cool water every hr
Elevate the head of the client's bed to a 15 angle
Replace the client's feeding bag every 72 hr
Check the client's gastric residual every 4 hr.
The Correct Answer is D
A. Irrigate the client's tube with 10 ml of cool water every hr: Flushing an NG tube is appropriate to maintain patency, but 10 mL is often insufficient for continuous feedings, and routine irrigation “every hr” is not standard practice. Flushing should follow facility protocol and be based on feeding type, residuals, or signs of tube blockage.
B. Elevate the head of the client's bed to a 15 angle: Elevating the head of the bed only 15 degrees is insufficient to reduce the risk of aspiration during continuous enteral feeding. Evidence-based practice recommends elevating the head of the bed to 30–45 degrees to promote gastric emptying and prevent reflux or aspiration.
C. Replace the client's feeding bag every 72 hr: Feeding bags for continuous enteral feedings should be replaced more frequently, typically every 24 hours, to reduce bacterial contamination and the risk of infection. Waiting 72 hours increases the likelihood of microbial growth and potential sepsis.
D. Check the client's gastric residual every 4 hr: Monitoring gastric residuals every 4 hours is an important action to assess tolerance to continuous tube feeding. High residuals can indicate delayed gastric emptying or intolerance, guiding decisions to hold or adjust the feeding, preventing aspiration and other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A brainstorming session with nurses: Brainstorming encourages open discussion and the generation of creative ideas to address a specific problem, such as rising rates of sexually transmitted infections. It allows the team to contribute multiple perspectives and potential interventions that can later be evaluated for feasibility and effectiveness.
B. A community-wide program: Implementing a program is an action step rather than a strategy for generating ideas. It is a solution that may be developed after identifying potential interventions through planning and brainstorming, rather than a method for idea generation itself.
C. Role playing with nurses: Role playing is a teaching and training strategy used to practice communication or counseling skills. While useful for preparing nurses to interact with clients, it does not generate new ideas for addressing a public health concern.
D. Personal discussions with clients: Talking with clients can provide valuable insight into individual behaviors and barriers, but it is not primarily a method for generating a broad range of innovative strategies. It serves more as a source of feedback or data rather than a creative ideation tool.
Correct Answer is C
Explanation
A. Type 1 diabetes mellitus: Type 1 diabetes is not directly linked to an increased risk of cervical cancer. While chronic illnesses can affect overall health, they are not specific risk factors for cervical neoplasia.
B. Hypertension: Hypertension is a cardiovascular condition and does not contribute to the development of cervical cancer. It is not considered a risk factor in gynecologic oncology.
C. History of STIs: A history of sexually transmitted infections, particularly human papillomavirus (HPV), is a major risk factor for cervical cancer. HPV infection can cause cellular changes in the cervix that may progress to malignancy if not detected and managed early.
D. Nulliparity: While nulliparity has been associated with a slightly increased risk in some cancers, it is not as significant a risk factor for cervical cancer as HPV or other STIs. The primary focus in cervical cancer risk assessment is exposure to HPV.
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.