A nurse is preparing to administer intermittent gastric feeding for a client who has a nasogastric tube. Which of the following actions should the nurse take prior to the feeding?
Apply sterile gloves.
Assess gastric residual volume.
Flush the tube with 60 mL of sodium chloride.
Chill the formula.
The Correct Answer is B
A. Apply sterile gloves: Standard precautions are followed when handling feeding equipment, but sterile gloves are not required for routine administration of intermittent gastric feedings. Clean gloves are sufficient to prevent contamination.
B. Assess gastric residual volume: Checking gastric residual volume before feeding helps evaluate the client’s tolerance of the previous feeding and reduces the risk of aspiration. High residual volumes may indicate delayed gastric emptying and the need to hold or adjust the feeding.
C. Flush the tube with 60 mL of sodium chloride: Flushing the tube is important before and after feedings to maintain patency, but the amount and timing depend on institutional protocol. It is performed after assessing residual volume rather than as the first step.
D. Chill the formula: Feeding formulas should generally be at room temperature to prevent gastrointestinal discomfort and cramping. Chilling the formula is not recommended prior to administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will use a loud tone of voice when speaking with the client.": Using a loud voice is unnecessary and can be perceived as patronizing. Expressive aphasia affects the client’s ability to communicate verbally, not their hearing, so volume does not improve understanding.
B. "I will repeat words not heard by the client.": Repeating words is not effective for clients with expressive aphasia, as their difficulty is in expressing language, not in hearing or comprehension. Repetition does not address the communication barrier.
C. "I will over articulate words when speaking.": Over-articulation is not typically helpful and may confuse the client. Clear, simple language and appropriate pacing are more effective than exaggerating speech.
D. "I will get the client's attention before speaking.": This statement indicates understanding of effective communication strategies for expressive aphasia. Gaining the client’s attention helps ensure they are focused and ready to process language, facilitating better interaction and comprehension.
Correct Answer is ["A","C","D"]
Explanation
A. WBC count 22,000/mm³ (5,000 to 10,000/mm³): Leukocytosis is a common finding in appendicitis due to the inflammatory and infectious process. A significantly elevated WBC count supports the diagnosis and indicates the body’s response to infection.
B. Diarrhea: Diarrhea is not a typical manifestation of appendicitis. Clients more commonly present with constipation or localized abdominal pain rather than frequent loose stools, so this finding is not characteristic.
C. Rebound tenderness: Rebound tenderness, especially in the right lower quadrant, is a classic sign of peritoneal irritation associated with appendicitis. Pain that increases when pressure is released is a key physical examination finding.
D. Low-grade fever: A low-grade fever often accompanies appendicitis due to the body’s inflammatory response. Fever typically develops as the condition progresses and can help differentiate appendicitis from other causes of abdominal pain.
E. Hyperactive bowel sounds: Hyperactive bowel sounds are more commonly associated with gastroenteritis or early intestinal obstruction. In appendicitis, bowel sounds are often normal or decreased, particularly if peritoneal irritation is present.
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