A charge nurse is observing a nurse administer intermittent tube feedings via an NG tube to a client.
Which of the following actions by the nurse should prompt the charge nurse to intervene?
The nurse allows the client to rest in a supine position during feeding.
The nurse irrigates the NG tube with tap water after feeding.
The nurse administers the feeding through a syringe barrel by gravity.
The nurse initiates the feeding after aspirating 50 ml of gastric residual.
The nurse initiates the feeding after aspirating 50 ml of gastric residual.
The Correct Answer is A
Choice A rationale
Allowing the client to rest in a supine position during feeding should prompt the charge nurse to intervene. The client should be in an upright position during feedings and for an hour afterwards to prevent aspiration.
Choice B rationale
Irrigating the NG tube with tap water after feeding is a standard practice. This helps to keep the tube patent and prevent blockages.
Choice C rationale
Administering the feeding through a syringe barrel by gravity is a common method for giving intermittent tube feedings. This method allows for controlled administration of the feeding.
Choice D rationale
Initiating the feeding after aspirating 50 ml of gastric residual is a standard practice. Checking gastric residual volume before feedings helps to assess gastric emptying and tolerance to the feeding.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
While it’s true that bulimia nervosa can have serious health consequences, telling the patient that they “should stop because they need to” may come across as dismissive of the patient’s struggle. It’s important to remember that bulimia nervosa is a complex mental health disorder that often requires professional treatment.
Choice B rationale
Asking the patient why they engage in their behavior might seem like a logical question, but it could potentially make the patient feel defensive or blamed for their condition. It’s important to approach the conversation with empathy and understanding.
Choice C rationale
While it’s important to validate the patient’s feelings and experiences, saying “I’m proud of you for recognizing that this behavior is not normal” might not be the most therapeutic response. This statement could potentially reinforce the idea that their behavior is “abnormal,” which could lead to feelings of shame or guilt.
Choice D rationale
Expressing empathy and understanding, as in “It seems like you are feeling helpless about this behavior,” can be a therapeutic response. This statement acknowledges the patient’s feelings and opens up the conversation for further exploration of their experiences and potential coping strategies.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.
Choice B rationale
Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.
Choice C rationale
Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.
Choice D rationale
Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.
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