A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
To confirm the placement of the NG tube
To determine the client's electrolyte balance
To remove gastric acid that might cause dyspepsia
To identify delayed gastric emptying
The Correct Answer is D
The nurse should measure the gastric residual before administering a feeding to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. Measuring gastric residual helps assess how well the client's stomach is emptying and can indicate if there is delayed gastric emptying.
By measuring gastric residual, the nurse can:
● Determine if the stomach has adequately emptied from the previous feeding. ● Assess the client's tolerance to enteral feedings.
● Detect signs of delayed gastric emptying, which can be indicative of gastrointestinal motility issues or other complications.
● Adjust the feeding rate or make other modifications to the enteral feeding plan based on the amount of residual volume.
Confirming the placement of the NG tube is typically done using other methods, such as an X-ray, pH testing, or auscultation of air insufflation. Gastric residual measurement primarily serves the purpose of assessing gastric emptying, rather than confirming tube placement.
While electrolyte imbalances can be monitored in the overall care of a client receiving enteral feedings, measuring gastric residual specifically focuses on assessing gastric emptying and feeding tolerance, rather than determining the client's electrolyte balance.
Removing gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. Gastric residual measurement aims to evaluate the volume of the previous feeding and assess gastric emptying, rather than focusing on dyspepsia specifically.
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Related Questions
Correct Answer is A,B,C,D,E
Explanation
When removing personal protective equipment (PPE) after caring for a client in contact isolation, the nurse should follow the steps in the following order:
1. Remove gloves.
2. Remove protective eyewear.
3. Remove gown.
4. Remove mask.
5. Perform hand hygiene.
By following this sequence, the nurse ensures that the removal of PPE is done in a way that minimizes the risk of contamination. Removing gloves first helps prevent the spread of potential contaminants on the hands. Removing protective eyewear next avoids any potential contact with the face or eyes during the removal process. Removing the gown comes next, followed by the mask. Lastly, performing hand hygiene after removing all PPE helps ensure the hands are thoroughly cleaned.
Correct Answer is ["25"]
Explanation
To calculate the infusion rate in drops per minute (gtt/min), we can use the following formula: Infusion rate (gtt/min) = (Volume to be infused (ml) * Drop factor) / Time (min) Given:
Volume to be infused: 100 ml
Drop factor: 60 gtt/ml
Time: 4 hr
First, we need to convert the time from hours to minutes:
4 hr * 60 min/hr = 240 min
Now, we can calculate the infusion rate:
Infusion rate (gtt/min) = (100 ml * 60 gtt/ml) / 240 min
Simplifying the equation:
Infusion rate (gtt/min) = 6000 gtt / 240 min
Dividing both sides:
Infusion rate (gtt/min) ≈ 25 gtt/min
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