The nurse is preparing to administer an enteral tube feeding to a client via a nasogastric tube. Which nursing action should be completed first?

Allow the formula to reach room temperature

Label feeding container with client's name and date/time hung

Aspirate stomach contents and check pH for tube placement

Assess residual volume

Answer and Explanation

The Correct Answer is C

C. This is a critical initial step before administering enteral feedings. Aspirating stomach contents helps confirm the placement of the nasogastric tube in the stomach rather than the respiratory tract. Checking the pH of the aspirate can further confirm gastric placement, as gastric fluid typically has an acidic pH (usually less than 5). This step ensures that the feeding will be delivered to the correct location, minimizing the risk of aspiration.
A. While it's important for the formula to be at an appropriate temperature for administration to prevent discomfort or complications such as cramping, this is not typically the first action to take. It can be done concurrently with other preparatory steps.
B. Proper labeling of the feeding container is essential for patient safety and adherence to institutional policies. However, this is not the first action to be completed. It's usually done after preparing the feeding and confirming the tube placement.
D. Assessing residual volume involves checking for any residual contents in the stomach from previous feedings. This step helps determine how much of the previous feeding remains in the stomach and whether it's safe to administer the next feeding. However, it typically follows confirming tube placement, as it's essential to know the tube is in the correct position before assessing residual volume.

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Correct Answer is D

Explanation

D. fluids and medications that may be irritating to peripheral veins can be given through a central venous access device (CVAD). CVADs are beneficial because they allow for the administration of vesicants, irritant solutions, or large volumes of fluid that could damage smaller, peripheral veins. They also provide reliable venous access for patients who are critically ill, have poor venous access, or require long-term medication treatment, such as for pain, infection, cancer, or to supply nutrition.
A. While central lines do have a risk of sepsis, it is not necessarily lower than peripheral sites
B. Patency confirmation methods are not exclusive to CVADs and are also applicable to peripheral IV catheters.
C. Both placement and maintenance require strict aseptic techniques to minimize the risk of infection.

A. Warmth and palpable cord along the vein B. A raised ecchymotic painful area C. Swelling and tenderness at the site D. Blanching and coolness of surrounding skin

Correct Answer is A

Explanation

A. These are indicative of inflammation within the vein, which is characteristic of phlebitis. Warmth is a common sign of inflammation, and the palpable cord suggests that the vein may be hardened or cord- like due to inflammation and irritation.
B. While this could indicate some form of vascular injury or extravasation, it is not a typical presentation of phlebitis. Phlebitis involves inflammation of the vein, which may cause redness, warmth, and tenderness along the course of the vein, but it typically does not manifest as a raised ecchymotic (bruised) area.
C. Swelling occurs due to inflammation within the vein, and tenderness is often present as a result of the irritation and inflammation. These symptoms are commonly observed in cases of phlebitis but are not specific.
D. These are not typical signs of phlebitis. Blanching (turning white) and coolness of the skin may suggest reduced blood flow to the area, which could occur in cases of ischemia or thrombosis but are not characteristic of phlebitis.

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The nurse is preparing to administer an enteral tube feeding to a client via a nasogastric tube. Which nursing action should be completed first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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