A nurse is providing care for a patient in a long-term care facility who is receiving enteral feedings via a nasogastric (NG) tube.
What action should the nurse take before administering the tube feeding?
Discard any residual gastric contents.
Position the patient in a low Fowler’s position.
Test the pH of the gastric aspirate.
Warm the feeding solution to body temperature.
The Correct Answer is C
Choice A rationale
Discarding any residual gastric contents before administering the tube feeding is not necessary and could lead to unnecessary loss of nutrients and electrolytes.
Choice B rationale
Positioning the patient in a low Fowler’s position is not the optimal position for administering a tube feeding. The patient should be in an upright position to reduce the risk of aspiration.
Choice C rationale
Testing the pH of the gastric aspirate is an important step before administering a tube feeding. This helps to verify that the feeding tube is in the stomach and not in the lungs.
Choice D rationale
Warming the feeding solution to body temperature is not necessary and could potentially lead to bacterial growth in the feeding solution.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Measuring the bladder before the patient voids would not provide an accurate measurement of postvoid residual, which is the amount of urine left in the bladder after voiding.
Choice B rationale
The position of the head of the bed does not directly impact the measurement of postvoid residual. However, the patient should be in a comfortable position during the procedure.
Choice C rationale
Similar to Choice B, the position of the head of the bed does not directly impact the measurement of postvoid residual.
Choice D rationale
Measuring the bladder within 15 minutes after the patient voids allows for an accurate measurement of postvoid residual, which can help assess bladder function.
Correct Answer is AANDD
Explanation
Choice A rationale
An ileostomy involves creating a stoma, or opening, in the abdominal wall. The location of the stoma is typically in the right lower abdomen.
Choice B rationale
The end of the stoma should not be painful after the procedure. If the patient experiences pain, it could indicate a complication and should be reported to the healthcare provider.
Choice C rationale
The patient should not expect the stoma to be a purple color. A healthy stoma should be red or pink. A purple stoma could indicate a lack of blood flow, which is a serious issue that needs immediate medical attention.
Choice D rationale
After an ileostomy, the patient will have liquid or semi-liquid stool pass through the stoma. This is because the large intestine, which normally absorbs water and forms solid stool, is bypassed or removed in the procedure.
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