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

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale

Broth is a clear liquid that can help replace sodium and chloride lost through diarrhea. However, it does not contain the necessary amounts of other electrolytes such as potassium and bicarbonate, which are also commonly lost in diarrhea.

Choice B rationale

Apple juice is not a good choice for a child with acute diarrhea. It is high in sugars and can worsen diarrhea. It also does not contain the electrolytes needed to replace those lost through diarrhea.

Choice C rationale

Cherry gelatin is not a suitable choice. While it is a clear liquid that can help with hydration, it does not contain the necessary electrolytes to replace those lost through diarrhea. It is also high in sugars, which can worsen diarrhea.

Choice D rationale

Pedialyte is the best choice for a child with acute diarrhea who reports that he is thirsty. It is a rehydration solution specifically designed to replace fluids and electrolytes lost through diarrhea.

A. Place the client in a supine position. B. Withdraw the tube if the client gags during insertion. C. Instruct the client to place his chin to his chest and swallow. D. Measure the tube for insertion from the tip of the nose to the umbilicus. E. Measure the tube for insertion from the tip of the nose to the umbilicus.

Correct Answer is C

Explanation

Choice A rationale

Placing the client in a supine position is not recommended during nasogastric tube insertion. The client should be in an upright position, such as sitting up or in a high Fowler’s position, to facilitate the passage of the tube and reduce the risk of aspiration.

Choice B rationale

Withdrawing the tube if the client gags during insertion is not the correct action. Gagging is a common reaction during nasogastric tube insertion. The nurse should pause and allow the client to rest and swallow. The tube should only be withdrawn if the client is unable to breathe or is extremely distressed.

Choice C rationale

Instructing the client to place his chin to his chest and swallow can facilitate the passage of the tube through the esophagus. This position closes off the trachea and opens the esophagus, reducing the risk of the tube entering the trachea.

Choice D rationale

Measuring the tube for insertion from the tip of the nose to the umbilicus is not the correct method. The correct measurement is from the tip of the nose to the earlobe and then down to the xiphoid process of the sternum.

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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)

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has acute diarrhea and reports that he is thirsty. Which of the following fluids should the nurse give the child?

Correct Answer is D

Explanation

Choice A rationale

Choice C rationale

Choice D rationale

The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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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)