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 A
Explanation
A. Monitor the dorsalis pedis pulse every 15 min: Frequent assessment of peripheral pulses, such as the dorsalis pedis, is essential after a cardiac catheterization to detect early signs of arterial occlusion, bleeding, or compromised circulation. Monitoring every 15 minutes during the initial post-procedure period allows timely identification of complications.
B. Place the client in Fowler's position: After a femoral cardiac catheterization, the client is typically positioned supine with the affected leg straight to minimize bleeding and hematoma formation. Fowler’s position can increase stress on the groin puncture site and is not recommended immediately post-procedure.
C. Keep the client NPO for 24 hr: NPO status is not routinely required for 24 hours following cardiac catheterization. Clients may resume oral intake as tolerated once hemodynamically stable, unless contraindicated for other medical reasons.
D. Maintain strict bedrest for the first 12 hr: While bedrest is necessary immediately post-procedure, strict immobility is usually required for 2–6 hours, depending on the type of closure device or sheath used. Maintaining 12 hours of strict bedrest is longer than standard protocol and may unnecessarily increase discomfort and risk of complications like urinary retention.
Correct Answer is D
Explanation
A. Ensure that the health care provider has consulted with another team member: While consultation may be part of ethical decision-making, it is not the primary action the nurse should take when a comatose client requires consent. The priority is confirming that informed consent is obtained from the appropriate decision-maker.
B. Ensure that the client's 16-year-old child supports the provider's decision for surgery: Minors cannot legally provide consent for medical procedures. The nurse should focus on the legal health care surrogate or guardian rather than the opinion of a minor child.
C. Determine if the procedure is medically necessary for the client: Assessing medical necessity is the provider’s responsibility. The nurse’s role is to advocate for the client by ensuring informed consent is obtained and the surrogate understands the procedure, risks, and benefits.
D. Determine if the health care surrogate understands the risks and benefits of the procedure: The nurse should confirm that the health care surrogate has received adequate information and understands the risks, benefits, and alternatives to the procedure. This ensures ethical and legal consent is obtained for a client unable to make decisions.
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