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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. In metabolic acidosis, the pH would be low (acidemic) and the HCO3 level would be below the normal range. In the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, indicating metabolic acidosis.
A. In respiratory alkalosis, the pH would be elevated (alkalotic) and the PaCO2 would be below the normal range (hypocapnia). However, in the provided ABG results, the pH is low (acidemia) rather than high, ruling out respiratory alkalosis.
B. In respiratory acidosis, the pH would be low (acidemic) and the PaCO2 would be above the normal range (hypercapnia). However, in the provided ABG results, the PaCO2 is within the normal range, ruling out respiratory acidosis.
C. In metabolic alkalosis, the pH would be elevated (alkalotic) and the HCO3 level would be above the normal range. However, in the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, ruling out metabolic alkalosis.
Correct Answer is B
Explanation
B. A PICC line is a long, flexible catheter inserted into a peripheral vein, typically in the upper arm, and advanced until the tip lies in the superior vena cava or the cavoatrial junction. PICC lines are suitable for long-term venous access and are often used for administering medications, including antibiotics, over several weeks or months. They offer stable and reliable access, reducing the need for frequent venipunctures.
A. Butterfly needles are typically used for short-term venous access, such as for blood draws or administering medications that do not require long-term therapy. They are not suitable for prolonged use or for administering medications over several weeks, as they are not designed for secure and stable access over an extended period.
C. A peripheral IV-lock, also known as a saline lock or heplock, is a short catheter inserted into a peripheral vein and then capped off for intermittent use. While peripheral IV-locks are suitable for short-term venous access, they are not ideal for prolonged therapy lasting several weeks. Additionally, they may not provide the necessary stability and reliability for administering IV antibiotics over an extended period.
D. A small gauge peripheral angiocath refers to a short catheter inserted into a peripheral vein for intravenous access. While a larger gauge catheter, such as a 16-gauge, may allow for faster infusion rates and is suitable for certain situations requiring rapid fluid administration, it may not be the most appropriate choice for long-term IV antibiotic therapy. The choice of gauge depends on factors such as the client's vein size, the viscosity of the medication, and the duration of therapy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today