A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube.
Which of the following actions should the nurse plan to take?
Measure gastric residual volumes every 4 hr.
Advance the rate of the feeding every 2 hr.
Maintain the head of the bed at a 20° angle.
Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication
The Correct Answer is A
The correct answer is choice A. Measure gastric residual volumes every 4 hr.
This is because continuous enteral feedings through an NG tube can increase the risk of aspiration, which is the inhalation of food or fluids into the lungs. Measuring gastric residual volumes (GRV) can help monitor the tolerance and absorption of the feedings and prevent overfeeding. GRV is the amount of fluid aspirated from the stomach via an enteral tube to check for gastric emptying. The normal range of GRV is less than 200 ml.
Choice B is wrong because advancing the rate of the feeding every 2 hr can lead to overfeeding, abdominal distension, nausea, vomiting and diarrhea.
The rate of the feeding should be adjusted according to the client’s nutritional needs and tolerance.
Choice C is wrong because maintaining the head of the bed at a 20° angle is not enough to prevent aspiration. The head of the bed should be elevated at least 30° to 45° during and for at least one hour after feeding.
Choice D is wrong because flushing the NG tube with 30 mL 0.9% sodium chloride before and after medication is not related to continuous enteral feedings. This is a practice to prevent clogging of the tube and ensure proper delivery of medication. Flushing the tube with water before and after feeding is also recommended to maintain patency and hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: While additional staff may be needed, the primary focus during a mass casualty event is triage and immediate care. Choice B rationale: Media relations are important, but the nurse's priority is direct patient care. Choice C rationale: Assessing incoming clients and determining their medical needs is crucial for prioritizing care and allocating resources effectively. Choice D rationale: Discharging stable clients may be necessary in extreme circumstances, but it is not the immediate priority. The focus should be on providing care to the influx of injured patients.
Correct Answer is ["B","C","D"]
Explanation
The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.
Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.
The nurse should provide a structured and consistent daily routine for the client.
Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.
The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.
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