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. Before administering an enteral feeding, it's important to discard any residual gastric contents to prevent aspiration. Aspirating and discarding the residual helps to assess gastric emptying and ensure that the stomach is able to tolerate the feeding.
B. While placing the client in a semi-Fowler's position is generally recommended during and after enteral feedings to help prevent aspiration, it's not necessary prior to administering the feeding.
C. Warming the feeding solution to body temperature can help to improve the client's comfort and may reduce nausea. However, it's not a critical step before administering the feeding.
D. Testing the pH of gastric aspirate is important to assess for gastric placement and to ensure that the tube is not in the lungs. However, it's typically done prior to the initial placement of the NG tube and is not routinely repeated before each feeding.
Correct Answer is D
Explanation
A. Crutches should not be used to support body weight under the arms, as this can cause nerve damage or discomfort. Instead, weight should be supported on the hands and arms, with the crutches positioned to support the client’s weight. Proper use involves placing the crutches slightly in front of the feet, with weight supported on the hands, not the underarms.
B. While it's important to be aware of your surroundings, looking down at your feet can be counterproductive as it may affect balance and coordination. The client should maintain an upright posture and look ahead to ensure proper gait and balance while moving. This helps in coordinating the movement of crutches and feet more effectively.
C. In a four-point gait, each crutch and foot move alternately, which is different from the three-point gait. The three-point gait involves moving both crutches and the affected leg forward simultaneously, followed by the unaffected leg.
D. In the three-point gait, the client moves both crutches forward at the same time while keeping the affected leg off the ground or in a non-weight-bearing position. Then, the client swings the unaffected leg forward to step past the crutches. This method ensures that weight is only placed on the unaffected leg while moving.
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