A nurse is caring for a patient 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 determine the patient’s electrolyte balance
To confirm the placement of the NG tube
To remove gastric acid that might cause dyspepsia
To identify delayed gastric emptying
The Correct Answer is D
Choice A rationale
While electrolyte balance is important in patient care, it is not the primary reason for measuring gastric residual before administering a feeding through an NG tube.
Choice B rationale
Confirming the placement of the NG tube is crucial before administering a feeding. However, measuring the gastric residual is not the primary method used to confirm tube placement.
Choice C rationale
Removing gastric acid that might cause dyspepsia is not the main purpose of measuring gastric residual. Dyspepsia, or indigestion, is typically managed with medications and dietary modifications.
Choice D rationale
The primary purpose of measuring gastric residual is to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. If gastric emptying is delayed, the nurse should avoid overfeeding the patient and causing gastric distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hyperactive reflexes are not typically associated with hypokalemia. Hypokalemia, or low potassium levels in the blood, can cause muscle weakness, fatigue, constipation, and arrhythmia.
Choice B rationale
Extreme thirst is not a typical symptom of hypokalemia. It is more commonly associated with conditions such as diabetes.
Choice C rationale
A weak, irregular pulse is a common symptom of hypokalemia. Low levels of potassium can affect heart function, leading to abnormal heart rhythms.
Choice D rationale
Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, constipation is a common symptom of this condition.
Correct Answer is D
Explanation
Choice A rationale
Requesting the providers to initiate antibiotic therapy for every patient on the unit is not the most appropriate action. Antibiotics should only be used when there is a confirmed bacterial infection. Overuse of antibiotics can lead to antibiotic resistance and can potentially trigger C. difficile infection due to disruption of normal gut flora.
Choice B rationale
While performing hand hygiene with an alcohol-based agent is important in general infection control, it is not the most effective measure against C. difficile.
C. difficile spores are resistant to destruction by alcohol-based hand rubs. Therefore, hand hygiene for C. difficile should involve washing with soap and water.
Choice C rationale
Obtaining stool cultures from all patients on the nursing unit is not the most appropriate action. Stool cultures should be obtained from patients who are symptomatic. Testing asymptomatic patients can lead to false positives and unnecessary treatment.
Choice D rationale
Placing all patients who have symptoms on contact precautions is the correct answer. Contact precautions, including the use of gloves and gowns, can prevent the spread of C. difficile. This is because C. difficile is spread via the fecal-oral route, and its spores can survive on surfaces for long periods.
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