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.

Answer and Explanation

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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Correct Answer is A

Explanation

A.Adequate protein intake is essential for skin repair and maintaining skin integrity. Protein helps in the healing process, supports the immune system, and strengthens the skin, making it more resistant to breakdown. This is a crucial intervention for preventing pressure ulcers and promoting overall skin health in older adults.

B.Massaging bony prominences is not recommended as it can cause friction and damage to already vulnerable skin, increasing the risk of skin breakdown rather than preventing it. Gentle repositioning is preferred to relieve pressure.

C.Clients at risk for skin breakdown should typically be repositioned at least every 2 hours, not every 3 hours, to relieve pressure and reduce the risk of developing pressure ulcers. Therefore, this option is not ideal as stated.

D.While keeping the skin dry is important, cornstarch is not recommended because it can cake and cause friction, which may lead to skin breakdown. Using moisture-wicking products or barrier creams is more appropriate for maintaining skin dryness and integrity.

A. "Inhale through the incentive spirometer 10 times with each use." B. "Use the incentive spirometer once every 4 hours." C. "Sit up at a 30-degree angle when using the incentive spirometer." D. "Hold your breath for 7 seconds when using the incentive spirometer."

Correct Answer is A

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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