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

Answer and Explanation

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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Correct Answer is B

Explanation

Measuring the output from an indwelling urinary catheter is within the scope of practice for an assistive personnel (AP). It involves a straightforward task that does not require specialized nursing knowledge or judgment.

The other tasks mentioned should not be delegated to an AP:

Administer an enteral feeding to a client who has a new gastrostomy tube: Administering enteral feedings requires specialized knowledge and training to ensure proper placement and administration. This task should be performed by a licensed nurse.

Evaluate a client's pain level 30 min after receiving an oral analgesic: Evaluating pain level and the effectiveness of pain management requires nursing assessment and judgment. This task should be performed by a licensed nurse.

Reinforce foot care to a client who has a new diagnosis of diabetes mellitus: Providing education and reinforcing foot care to a client with a new diagnosis of diabetes requires

specialized knowledge about the disease and its management. This task should be performed by a licensed nurse.

A. Remove the bottle cap. B. Place the bottle cap inside up on clean surface. C. Pick up the bottle with the label facing his palm. D. Pour 1 to 2 mL into a receptacle. E. Pour the solution onto the gauze.

Correct Answer is C,A,D,E,B

Explanation

To pour the sterile solution onto a piece of gauze, the nurse should perform the steps in the following order:

1. Pick up the bottle with the label facing his palm.

2. Remove the bottle cap.

3. Pour 1 to 2 mL into a receptacle.

4. Pour the solution onto the gauze.

5. Place the bottle cap inside up on a clean surface.

It is important to maintain sterility throughout the procedure to prevent contamination. By following this order, the nurse ensures that the solution is poured onto the gauze while minimizing the risk of contamination. Placing the bottle cap inside up on a clean surface after removing it helps maintain the sterility of the cap as well.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse planning care for a group of clients is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Correct Answer is B

Explanation

A nurse assisting a provider with a sterile procedure prepares to pour a sterile solution onto a piece of gauze. In which order should the nurse perform the steps of pouring the solution? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is C,A,D,E,B

Explanation

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