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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Unplugging the cord by holding the plug is a good practice to prevent electrical hazards, but it is not the most important action when administering intravenous fluids.
Choice B rationale
Ensuring the plug has three prongs is the most important action to prevent electrical hazards when administering intravenous fluids. A three-prong plug is grounded and reduces the risk of electrical shock.
Choice C rationale
Avoiding rolling equipment over extension cords is a good practice to prevent electrical hazards, but it is not the most important action when administering intravenous fluids.
Choice D rationale
Plugging in the pump close to the socket is a good practice to prevent electrical hazards, but it is not the most important action when administering intravenous fluids.
Correct Answer is C
Explanation
The correct answer is Choice C.
Step 1 is to interpret the laboratory values. The glucose level is within the normal range (7099 mg/dL). The chloride level is within the normal range (97-107 mEq/L). The sodium level is within the normal range (135-145 mEq/L). However, the potassium level is low (normal range is 3.5-5.0 mEq/L)89101112.
Step 2 is to plan the action based on the interpretation. Given the low potassium level, the nurse should plan to request a potassium replacement
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