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.
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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.
Correct Answer is ["A","B","C"]
Explanation
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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