A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. (Move the steps, placing them in the selected order of performance. All steps must be used.)
Verify tube placement
Check the residual feeding contents
Evaluate tolerance of feeding
Administer the feeding
The Correct Answer is A,B,D,C
A. Verify tube placement: This is the first step to ensure that the tube is in the correct position and not in the lungs, which could lead to aspiration.
B. Check the residual feeding contents: This helps to assess gastric emptying and ensure that the stomach can tolerate the feeding. If there is a large amount of residual, the feeding may be delayed or the rate may need to be adjusted.
D. Administer the feeding: Once tube placement is confirmed and residual contents are assessed, the feeding can be administered at the prescribed rate.
C. Evaluate tolerance of feeding: After the feeding is complete, it's important to monitor the client for signs of tolerance, such as the absence of nausea, vomiting, or abdominal distension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Using a friction-reducing device, such as a slide sheet or transfer sheet, is a recommended method for moving clients with partial assistance needs. The device reduces friction, making it easier and safer to reposition or move the client with minimal physical strain. Two nurses working together with a friction- reducing device can effectively and safely move the client while minimizing the risk of injury for both the client and the nurses.
B. This method is not ideal for moving clients who have limited mobility or who are only partially able to assist. Relying on the client to push with their feet while the nurse lifts can be unsafe and ineffective,
especially if the client’s strength or coordination is compromised.
C. Lifting a client under the shoulders can be uncomfortable and potentially harmful for the client, especially if they have limited mobility or if proper body mechanics are not used. This method also places significant strain on the nurses’ backs and may lead to injury.
D. A trapeze bar can be a helpful aid for clients who have some upper body strength and can assist with repositioning. However, relying solely on one nurse to lift the client’s legs while the client uses the trapeze bar may not provide adequate support for a complete and safe repositioning.
Correct Answer is A
Explanation
A. A urine output of 175 mL over 8 hours is significantly below normal, which is generally considered less than 0.5 mL/kg/hr in adults (the normal range is about 0.5-1.5 mL/kg/hr). Reduced urine output can be indicative of acute kidney injury or worsening renal function, and it needs prompt evaluation and intervention.
B. This finding is generally not urgent but could be noted. Strong-smelling urine, especially in the morning, may be due to concentration of waste products overnight or dietary factors. While it might suggest dehydration or infection, it is less immediately concerning than changes in urine output. If accompanied by other symptoms such as pain, fever, or changes in urine color, it might warrant further investigation.
C. This finding is typically within normal limits and may not need immediate reporting. Normal urine output is about 800-2,000 mL per day. An output of 2,200 mL is slightly elevated but still within the normal range, depending on fluid intake.
D. This finding is generally not urgent but worth noting. Cloudy urine can result from the presence of cells, bacteria, or other substances. It may become cloudy after standing due to the formation of crystals or precipitation of substances.
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