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 D
Explanation
A. Palpate the abdomen: Palpating the abdomen before auscultating bowel sounds could potentially alter the findings by stimulating peristalsis or causing discomfort in the client, particularly in cases of appendicitis or other acute abdominal conditions.
B. Administer an antiemetic:A thorough assessment, including auscultation of bowel sounds, is needed first to rule out conditions like a bowel obstruction or paralytic ileus where antiemetics may be contraindicated.
C. Offer pain medication:Pain medication can mask symptoms and interfere with the nurse's or physician's ability to accurately assess the underlying cause of the client's symptoms, such as appendicitis.
D. Auscultate bowel sounds:Auscultating bowel sounds is the first action the nurse should take because it is a non-invasive assessment that can provide critical information. It helps determine if bowel sounds are present, hyperactive, hypoactive, or absent, which can guide further interventions and diagnostic steps.
Correct Answer is A
Explanation
As individuals age, it is common for them to experience a decreased sense of balance. This can be attributed to age-related changes in the musculoskeletal system, sensory perception, and coordination. The inner ear, which plays a vital role in maintaining balance, undergoes natural degenerative changes over time. Additionally, age-related decline in muscle strength and flexibility can contribute to difficulties in maintaining balance. Therefore, a nurse assessing an older adult client should expect a decreased sense of balance as a common finding.
- Nighttime urinary incontinence: While nighttime urinary incontinence can occur in some older adults, it is not a universal finding. It is important to avoid making assumptions or generalizations about older adults experiencing urinary incontinence. Each individual's urinary function can vary, and incontinence can be influenced by various factors such as overall health, bladder capacity, medication use, and underlying medical conditions.
- Heightened sense of pain: Older adults may experience changes in pain perception due to age-related physiological changes and medical conditions. However, it is not a predictable or expected finding for all older adult clients. Pain perception can vary among individuals based on their overall health, chronic conditions, and individual pain thresholds. Therefore, while some older adults may experience heightened pain sensitivity, it is not a universal expectation.
- Increased nighttime sleeping: Sleep patterns can change with age, and older adults may experience alterations in their sleep-wake cycles. However, increased nighttime sleeping is not a definitive finding that applies to all older adult clients. Sleep patterns can vary greatly among individuals, and some older adults may experience decreased sleep duration or disrupted sleep rather than increased nighttime sleeping.
In summary, the nurse should expect a decreased sense of balance as a common finding when assessing an older adult client. It is important to approach each individual as unique and recognize that other findings such as nighttime urinary incontinence, heightened sense of pain, or increased nighttime sleeping may or may not be present, as they can vary among older adults based on individual factors.

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