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 B

Explanation

B. This statement aligns with the concept of allostatic load, which refers to the cumulative physiological toll that chronic stress places on the body over time. Initially, the body's stress response system (the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system) is designed to help individuals cope with acute stressors. However, when stress becomes chronic, these physiological responses can become dysregulated and maladaptive, leading to negative health outcomes such as cardiovascular disease, immune dysfunction, and mental health disorders.
A. Chronic stress has been associated with various changes in gene expression and epigenetic modifications. However, these changes typically occur over longer periods and are not the primary mechanism by which chronic stress leads to illness in most cases.
C. Chronic stress can lead to dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system, which are responsible for producing and regulating corticosteroids (such as cortisol) and catecholamines (such as adrenaline and noradrenaline). While acute stress typically results in increased production of these stress hormones, chronic stress can lead to desensitization and dysregulation of these systems, resulting in alterations in hormone levels and potential deficits in the availability of these stress mediators. However, deficits in corticosteroids and catecholamines are not the sole mechanism by which chronic stress leads to illness.
D. While chronic stress can certainly contribute to psychological fatigue and depletion of energy reserves, this is not the primary mechanism by which chronic stress leads to illness. The physiological responses to chronic stress, such as dysregulation of stress hormones, inflammation, and oxidative stress, are more directly linked to the development of various illnesses.

A. Research shows that people in general get more than enough sleep. B. Teenagers have a natural tendency to wake up earlier. C. Sleep needs remain constant over the course of a person's lifetime. D. Older adults experience a progressive decrease in deep sleep.

Correct Answer is D

Explanation

D. As individuals age, there is a natural decline in the amount of deep sleep (slow-wave sleep or Stage N3 sleep) they experience. Older adults tend to spend less time in deep sleep and may experience more fragmented sleep patterns, with more frequent awakenings during the night. This reduction in deep sleep is a normal part of the aging process and is associated with changes in sleep architecture and physiology.
A. Research indicates that a significant portion of the population does not get enough sleep, with many adults experiencing sleep deprivation due to various factors such as lifestyle, work schedules, and sleep disorders.
B. Teenagers often have a natural tendency to stay up later and have difficulty waking up early due to changes in their circadian rhythm during adolescence. This shift in sleep patterns, known as delayed sleep phase syndrome, can result in later bedtimes and waking times for teenagers.

C. Sleep needs typically change over the course of a person's lifetime. Infants and young children require more sleep than adults, with sleep duration gradually decreasing as individuals age.
Additionally, factors such as lifestyle, health status, and environmental influences can affect sleep needs at different stages of life.

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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 B

Explanation

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Correct Answer is D

Explanation

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