A nurse is caring for a client who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the formula?
Encourage the client to take sips of water.
Check for gastric residual volume.
Flush the tube with sterile 0.9% sodium chloride irrigation.
Encourage the client to breathe deeply and cough.
The Correct Answer is B
Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.
a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.
c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.
d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.
Option b is incorrect because offering the client sips of a citrus flavored soda may not be appropriate for all clients and should be based on individual preferences and needs.
Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.
Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.
Correct Answer is D
Explanation
When caring for a client who has a chest tube following thoracic surgery, the nurse can delegate the task of assisting the client to select food choices from the menu to an assistive personnel. This task is within the scope of practice of an assistive personnel and does not require the specialized knowledge or judgment of a nurse.
Option a is incorrect because monitoring the characteristics of the client's chest tube drainage requires specialized knowledge and should not be delegated.
Option b is incorrect because evaluating the client's response to pain medication requires specialized knowledge and should not be delegated.
Option c is incorrect because teaching deep breathing and coughing to the client requires specialized knowledge and should not be delegated.
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