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 B
Explanation
B. Negligence refers to the failure to exercise reasonable care that results in harm to another person. It occurs when a healthcare provider fails to perform their duties according to the standard of care expected in their profession, leading to injury or harm to the patient. In the scenario described, the failure to follow orders for turning and positioning, resulting in pressure injuries, is an example of negligence. Negligence can result from actions (acts of commission) or omissions (acts of omission).
A. Battery refers to the intentional harmful or offensive touching of another person without their consent. In healthcare, battery may occur if a medical procedure is performed on a patient without their informed consent or if a procedure goes beyond the scope of what was consented to. In the context of the scenario provided, the development of pressure injuries due to inadequate turning and positioning is not an example of battery because it does not involve intentional harm.
C. Assault refers to the intentional threat of harm or the creation of fear of imminent harm in another person. In healthcare, assault may occur if a healthcare provider threatens a patient with harm or performs a procedure without their consent, creating fear or apprehension in the patient. In the context of the scenario provided, the development of pressure injuries due to inadequate turning and positioning is not an example of assault because it does not involve intentional threats or actions creating fear in the patient.
D. A felony is a serious criminal offense punishable by imprisonment or death. It typically involves actions that are considered extremely harmful or dangerous to society. The scenario described does not involve actions that rise to the level of a felony offense.
Correct Answer is B
Explanation
B. This client's excitement to learn about a new prosthesis indicates a positive attitude towards rehabilitation and a willingness to engage in the learning process. Their enthusiasm suggests a high level of motivation to adapt to their new prosthesis and incorporate it into their daily life. Therefore, this client exhibits a high motivation to learn.
A. This client's struggle with following nursing directives regarding discharge goals suggests a lack of motivation or difficulty engaging in the rehabilitation process. They may be experiencing challenges or barriers that are impeding their progress. Therefore, they do not exhibit the highest motivation to learn at this time.
C. While this client may have valuable experience and insights to share with newcomers, being a "coach" does not necessarily indicate a high motivation to learn for themselves. While they may be motivated to help others, it doesn't necessarily reflect their own eagerness to engage in learning activities for their own rehabilitation goals.
D. This client's eagerness to be discharged may suggest a desire to move on from the rehabilitation facility rather than a motivation to engage in learning activities related to their rehabilitation. They may be more focused on the end goal of leaving the facility rather than actively participating in the rehabilitation process.
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