A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
The nurse administers the feeding through a syringe barrel by gravity.
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 initiates the feeding after aspirating 50 mL of gastric residual.
The Correct Answer is B
A. The nurse administers the feeding through a syringe barrel by gravity.
This is an appropriate method for administering intermittent tube feedings. Gravity feeding with a syringe allows for controlled delivery of the feeding solution.
B. The nurse allows the client to rest in a supine position during feeding.
Feeding a client in a supine position is generally acceptable, especially if the client is comfortable and doesn't experience complications. However, if there are specific contraindications or concerns for aspiration, the nurse should follow the prescribed position guidelines.
C. The nurse irrigates the NG tube with tap water after feeding.
Using tap water to irrigate an NG tube is not recommended, as it may lead to complications such as electrolyte imbalances. Sterile or distilled water should be used for irrigation.
D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
This is an appropriate action. Aspirating gastric residual before initiating a feeding helps assess the presence of gastric contents, ensuring that the client is ready to receive the feeding. However, specific institutional policies may dictate the threshold for gastric residual volume that requires intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Report of decreased urinary output
Explanation: Decreased urinary output is not typically associated with hyperglycemia. In fact, increased urinary output (polyuria) is more characteristic.
B. Random blood glucose 126 mg/dL
Explanation: This level is within the normal range for random blood glucose. Hyperglycemia is usually defined by higher blood glucose levels.
C. Clammy skin
Explanation: Clammy skin is not a direct manifestation of hyperglycemia. Symptoms of hyperglycemia may include increased thirst, frequent urination, and blurred vision.
D. History of poor wound healing
Explanation: This is correct. Hyperglycemia can contribute to impaired wound healing, as it affects the body's ability to repair tissues.
Correct Answer is C
Explanation
A. High-fiber cereals:
High-fiber cereals may not be suitable for a soft diet, as they can be challenging to chew and may not meet the texture requirements of a soft diet.
B. Raw vegetables:
Raw vegetables are generally not recommended for a soft diet, as they can be difficult to chew and digest. Cooking or steaming vegetables can make them softer and more suitable for a soft diet.
C. Ground beef:
This is the correct answer. Ground beef can be included in a soft diet, especially if it is cooked to a tender consistency. It provides a good source of protein while meeting the requirements of a soft-textured diet.
D. Fruit with the skin:
Fruits with skins may pose a challenge for individuals on a soft diet, as the skin can be difficult to chew and swallow. Choosing peeled or canned fruits without skins may be more appropriate.
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