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

When checking a client's blood pressure, the nurse should use a cuﬀ with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuﬀ fits properly and provides an accurate reading.

Options b, c, and d are not correct. The cuﬀ should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

A. Ask what the client knows about the eﬀects of smoking. B. Work with the client to establish a quit date. C. Suggest that the client use nicotine gum to facilitate quitting. D. Refer the client to a local smoking cessation program.

Correct Answer is A

Explanation

If a nurse is caring for an older adult client who tells the nurse that they have smoked one pack of cigarettes every day for the last 60 years, the next action the nurse should take is to ask what the client knows about the eﬀects of smoking. This will help the nurse assess the client's knowledge and understanding of the risks associated with smoking and provide an opportunity for education.

Option b is incorrect because working with the client to establish a quit date is important but not the next intervention.

Option c is incorrect because suggesting that the client use nicotine gum to facilitate quitting is important but not the next intervention.

Option d is incorrect because referring the client to a local smoking cessation program is important but not the next intervention.

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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 preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who tells the nurse, "I have smoked one pack of cigarettes every day for the last 60 years." Which of the following actions should the nurse take next?

Correct Answer is A

Explanation

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