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

Wound dehiscence can lead to infection, bleeding, and evisceration (protrusion of internal organs through the incision). The nurse should report this finding to the provider immediately and cover the wound with a sterile dressing moistened with sterile saline solution.
Choice A is wrong because mild swelling under the sutures near the incisional line is a normal finding in the early stages of wound healing. It does not indicate infection or dehiscence unless accompanied by other signs such as redness, warmth, pain, or purulent drainage.
Choice B is wrong because crusting of exudate on the incisional line is also a normal finding that indicates the formation of a scab.
A scab protects the wound from infection and helps it heal faster. The nurse should not remove the scab unless instructed by the provider.
Choice D is wrong because pink-tinged coloration on the incisional line is another normal finding that shows healthy granulation tissue.
Granulation tissue is new tissue that fills in the wound and helps it close. It is usually pink or red and moist.
The nurse should follow these general tips for postoperative abdominal incision care:
- Always wash your hands before and after touching your incisions.
- Inspect your incisions and wounds every day for signs your healthcare provider has told you are red flags or concerning.
- Look for any bleeding.
If the incisions start to bleed, apply direct and constant pressure to the incisions.
- Avoid wearing tight clothing that might rub on your incisions.
- Try not to scratch any itchy wounds.
- You can shower starting 48 hours after your operation but no scrubbing or soaking of the abdominal wounds in a tub.
- After the initial dressing from the operating room is removed, you can leave the wound open to air unless there is drainage or you feel more comfortable with soft gauze covering the wound.
- Surgical glue (Indermil) will fall off over a period of up to 2-3 weeks.
Do not put any topical ointments or lotions on the incisions.
- Do not rub over the incisions with a washcloth or towel.
- No tub baths, hot tubs, or swimming until evaluated at your clinic appointment.
Correct Answer is D
Explanation
Choice A reason:
"I try to respond to the baby quickly so she doesn't cry very long." This statement is incorrect because it indicates the parent's sensitivity to the baby's needs and responsiveness to the baby's cues, which are positive signs of appropriate caregiving.
Choice B reason:
"I have several friends who come by to help out with the baby." This statement is incorrect because having a support system in the form of friends who help with the baby is a positive factor that can reduce stress and promote a healthy postpartum period.
Choice C reason:
"I want to meet other parents to see if they are going through the same things." This statement is incorrect because seeking social support and connecting with other parents can be beneficial in reducing feelings of isolation and stress during the postpartum period.
Choice D reason:
"I think the baby should be sleeping through the night by now is the correct statement "I think the baby should be sleeping through the night by now," as a manifestation of increased risk for child abuse. This statement may indicate unrealistic expectations or frustration from the parent regarding the baby's sleep patterns.
It is common for newborns to wake frequently during the night for feeding and care, and their sleep patterns can vary significantly in the early weeks and months of life. Unrealistic expectations or frustration about the baby's sleep habits can contribute to increased stress for the parent, which might increase the risk of child abuse or neglect.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
