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A nurse is preparing to administer an intermittent enteral feeding through a small-bore NG tube. Which of the following actions should the nurse take before initiating the feeding?

A.

Flush the tube with 5 mL of water.

B.

Test the pH of fluid aspirated from the tube.

C.

Inject air through the tubing and auscultate for gurgling sounds:

D.

Change the bag and tubing system every 12 hr

Answer and Explanation

The Correct Answer is B

A. Flush the tube with 5 mL of water:

Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.

B. Test the pH of fluid aspirated from the tube (Correct Answer):

Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.

C. Inject air through the tubing and auscultate for gurgling sounds: 

Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.

D. Change the bag and tubing system every 12 hr:

Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.


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Related Questions

Correct Answer is A

Explanation

A. Use an air-assisted device.

Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.

B. Position the bed in reverse Trendelenburg:

Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.

C. Elevate the head of bed to a 45° angle:

While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.

D. Lower the bed close to the ground:

Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.

Correct Answer is C

Explanation

A. Beneficence:

Beneficence is the ethical principle of doing good or promoting the well-being of the patient. In this scenario, the nurse is respecting the client's autonomy rather than actively promoting a specific course of action.

B. Fidelity:

Fidelity refers to the principle of being faithful or keeping promises. While being truthful and honest with the client is important, the nurse's response is primarily addressing the client's autonomy.

C. Autonomy:

This is the correct answer. Autonomy is the ethical principle that emphasizes the individual's right to make decisions about their own care, including the right to refuse treatment. The nurse's response acknowledges and respects the client's autonomy in deciding to discontinue enteral feedings.

D. Justice:

Justice pertains to fairness and equitable distribution of resources. It is not the primary ethical principle being demonstrated in this scenario, as the focus is on the individual's right to make a decision about their own care.

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