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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nurse should provide written materials in the client's primary language for a client who requires teaching prior to discharge. This ensures that the client has access to important information in a language they understand and can refer to after leaving the facility.

b. A client who is watching a video about meal services in their primary language may not require additional written materials.

c. A client who is learning to use an incentive spirometer with the help of an interpreter may not require additional written materials.

d. The administration of a prescribed pain medication does not necessarily require the provision of written materials.

A. Explain the techniques of esophageal speech. B. Schedule a support session for the client. C. Determine the client's reading ability. D. Review the use of an artificial larynx with the client. E. None F. None

Correct Answer is C

Explanation

A. Explain the techniques of esophageal speech.Esophageal speech is one method of communication but is learned later through speech therapy. Not the immediate priority.

B. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.

C. Determine the client's reading ability.After surgery, the client will not be able to speak initially. Knowing if the client can read and write allows the nurse to provide a communication method (such as writing or using a communication board) to meet immediate needs, especially related to airway, pain, and care.

D. Review the use of an artificial larynx with the client.An electrolarynx is an option but is introduced later in recovery. It is not the immediate concern before surgery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients whose primary languages are diﬀerent from the nurse's. For which of the following clients should the nurse provide written materials in the client's primary language?

Correct Answer is A

Explanation

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

Correct Answer is C

Explanation

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