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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An elevated white blood cell (WBC) count in a urinalysis can indicate an infection or inflammation in the body. A count of 10 is higher than the normal range, which is typically 0 to 5 WBCs per high power field.
Choice B rationale
Occasional casts in the urine are not typically a cause for concern. Casts are tiny tube-shaped particles that can form due to kidney conditions, but occasional casts can be normal.
Choice C rationale
A pH of 5.0 is within the normal range for urine pH, which is typically between 4.6 and 8.0.
Therefore, this result would not typically need to be communicated to the provider.
Choice D rationale
Dark amber color of the urine can be a sign of dehydration, but it can also be influenced by certain foods, medications, and health conditions. It is not typically a result that needs to be communicated to the provider.
Correct Answer is C
Explanation
Choice A rationale
Irrigating the nasogastric tube with tap water is not recommended. Tap water is not sterile and can introduce bacteria into the stomach, potentially causing infection.
Choice B rationale
Marking abdominal girth once daily is not sufficient for a client who is postoperative following peritoneal lavage for peritonitis. This client is at risk for complications such as abscess formation and bowel obstruction, which can cause rapid changes in abdominal girth. Therefore, abdominal girth should be measured more frequently.
Choice C rationale
Placing the client in a high Fowler’s position is the correct intervention. This position, which involves the client sitting up at an angle of 45 to 60 degrees, can help reduce pressure on the abdominal area, promote better lung expansion, and facilitate drainage of gastric contents, thus reducing the risk of aspiration.
Choice D rationale
Ambulating the client twice daily is not appropriate in this case. The client has just undergone a major abdominal surgery and has a nasogastric tube and closed-suction drains in place. Early ambulation may not be feasible due to the risk of dislodging the drains or causing pain and discomfort.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today