A nurse is caring for a patient in a long-term care facility who is receiving enteral feedings via an NG tube.
Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply)
Auscultate stomach sounds
Warm the formula to body temperature
Assist the client to sit in an upright position
Discard residual gastric contents
Correct Answer : A,B,C
Choice A rationale
Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.
Choice B rationale
Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.
Choice C rationale
Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.
Choice D rationale
Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
An increased blood osmolarity, such as 260 mOsm/kg, can be a sign of dehydration. When the body is dehydrated, the concentration of solutes in the blood can increase, leading to higher osmolarity.
Choice B rationale
Hypotension, or low blood pressure, is not typically a sign of dehydration. In fact, dehydration can often cause blood pressure to increase due to the body’s efforts to compensate for the lack of fluid.
Choice C rationale
A high urine specific gravity, such as 1.035, can indicate dehydration. This measurement reflects the concentration of solutes in the urine, and a high value can mean that the body is conserving water due to dehydration.
Choice D rationale
An elevated blood sodium level, such as 150 mEq/L, can be a sign of dehydration. When the body is dehydrated, the concentration of sodium in the blood can increase.
Correct Answer is B
Explanation
Choice A rationale
Pushing the syringe plunger to empty the formula faster is not recommended. This can lead to complications such as aspiration, diarrhea, or abdominal cramping. The formula should be allowed to flow slowly by gravity.
Choice B rationale
Holding the syringe high enough for the formula to empty gradually by gravity is the correct method for intermittent feeding. This allows for a slow, controlled flow of the formula, which can help prevent complications.
Choice C rationale
Positioning the patient in a supine position during feeding is not recommended. The patient should be in an upright position, at least 30 degrees, to reduce the risk of aspiration.
Choice D rationale
Flushing the tubing before feeding only is not correct. The tubing should be flushed before and after feedings to maintain patency and prevent clogging.
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