A nurse is caring for a client who is receiving enteral feedings via NG tube. Which of the following actions should the nurse take prior to administering the formula?
Check for gastric residual volume.
Flush the tube with sterile 0.9% sodium chloride irrigation.
Encourage the client to take sips of water.
Encourage the client to breathe deeply and cough.
The Correct Answer is A
A. Before administering enteral feeding, it is important to check the gastric residual volume to ensure that the previous feeding has been adequately digested and to reduce the risk of aspiration. High residual volumes can indicate delayed gastric emptying and may require holding the feeding.
B. While it is important to flush the tube, this is typically done with water (sterile or tap) rather than sterile 0.9% sodium chloride, unless specifically ordered for medical reasons. The primary step before feeding is to check the residual volume.
C. Encouraging the client to take sips of water is not applicable in the context of enteral feeding via NG tube, as the feeding is delivered directly into the stomach or intestines.
D. Encouraging deep breathing and coughing is not relevant to the administration of enteral feedings via an NG tube. These actions are more related to respiratory care.
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Correct Answer is A
Explanation
A tracheostomy is a surgical opening in the neck that allows air to enter the lungs through a tube called a tracheostomy tube. The tube has two parts: an outer cannula that stays in place and an inner cannula that can be removed for cleaning. The tracheostomy ties are used to secure the tube to the neck and prevent it from falling out. They should be adjusted to allow one finger to fit snugly underneath, so that they are not too tight or too loose.
Correct Answer is A
Explanation
The nurse should explain the need to have another adult drive the client home following surgery, as this is a safety measure to prevent complications such as bleeding, infection, or injury due to impaired cognition or mobility after anesthesia or sedation. The nurse should ask the client to shower once with an antiseptic soap on either the night before or morning of surgery, not 3 times the day before surgery, as this can reduce the risk of surgical site infection. The nurse should inform the client that they cannot wear makeup during surgery, as this can interfere with the monitoring of skin color and oxygen saturation. The nurse should instruct the client to stop drinking clear liquids at least 2 hours before surgery, not 1 hour before surgery, as this can reduce the risk of aspiration and gastric distension.
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