A nurse is managing nutrition for a client who is receiving intermittent enteral feedings through a nasogastric tube. Which of the following actions should the nurse take first?

Draw up the formula into a syringe.

Determine the pH level of gastric contents.

Flush the nasogastric tube with 30 mL of water.

Measure the total volume of gastric residual.

Answer and Explanation

The Correct Answer is B

A. Draw up the formula into a syringe. This step is premature and should be done after confirming the tube placement and checking for residual volume.
B. Determine the pH level of gastric contents. Checking the pH level of gastric contents helps confirm the placement of the nasogastric tube in the stomach, which is crucial before administering feedings or medications to prevent aspiration.
C. Flush the nasogastric tube with 30 mL of water. Flushing is important but should be done after confirming tube placement.
D. Measure the total volume of gastric residual. Measuring residual volume is important but should be done after confirming tube placement.

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Correct Answer is A

Explanation

A. Compile a list of the client's current medications to compare with new medications. Medication reconciliation is a key component of The Joint Commission's National Patient Safety Goals. It helps prevent medication errors by ensuring that all medications are reviewed and documented.
B. Label syringes, but not medicine cups or basins, during a procedure. All medications and solutions should be labeled to prevent medication errors, including those in syringes, medicine cups, and basins. Not labeling all items can lead to confusion and errors.
C. Use one client identifier for treatments, care, and services. Using at least two identifiers (e.g., name and date of birth) is recommended to ensure correct patient identification and reduce the risk of errors.
D. Perform a daily assessment of wounds using the Braden scale. The Braden scale is used for assessing pressure ulcer risk, not for daily wound assessment. While regular assessment of wounds is important, the Braden scale is not the correct tool for this purpose.

A. Align the bottom of the meniscus of the liquid with the container scale. B. Turn the bottle so the label is visible when pouring. C. Place the medication cap on the table with the inside of the cap facing down. D. Hold the medication cup when pouring from the bottle.

Correct Answer is A

Explanation

A. Align the bottom of the meniscus of the liquid with the container scale. This ensures accurate measurement of the liquid medication.
B. Turn the bottle so the label is visible when pouring. The label should be facing the nurse to prevent spilling medication on it and making it unreadable.
C. Place the medication cap on the table with the inside of the cap facing down. The cap should be placed with the inside facing up to maintain cleanliness and prevent contamination.
D. Hold the medication cup when pouring from the bottle. The medication cup should be placed on a flat surface to ensure accurate measurement and avoid spills.

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A nurse is managing nutrition for a client who is receiving intermittent enteral feedings through a nasogastric tube. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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