A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?

Cleanse the top of the can of formula with an alcohol wipe.

Keep the formula cold until instillation.

Withhold the feeding if the residual volume is 150 mL.

Flush the tube with 30 mL of sterile water before the feeding.

None

Answer and Explanation

The Correct Answer is A

Correct answer: D

A. Wiping the top of the can before opening prevents contamination and reduces the risk of introducing pathogens into the feeding system.

B. Cold formula can cause gastric discomfort or cramping. It's recommended to bring the formula to room temperature before administration to avoid gastric irritation and enhance comfort during feeding.

C. The action of withholding the feeding depends on the institution's protocol and the specific clinical condition of the client. Typically, residuals greater than 200 mL might indicate delayed gastric emptying, but the threshold can vary. A residual volume of 150 mL may not necessarily require withholding the feeding, though it may warrant further assessment.

D. In most cases, flushing is done with tap water (if safe for drinking) or sterile water in immunocompromised clients. The key step is to flush before and after feedings, but the standard practice is not automatically sterile water for all patients.

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Correct Answer is B

Explanation

A. Diarrhea:
Explanation: Vomiting is more likely to be associated with dehydration than diarrhea. While vomiting and diarrhea can both lead to fluid loss, dehydration is a more immediate concern.

B. Dehydration:
Explanation: This is correct. Vomiting can lead to a significant loss of fluids, and dehydration is a potential complication. It's important to monitor the client's fluid balance, provide oral rehydration solutions or intravenous fluids as needed, and address the underlying cause of vomiting.

C. Urinary frequency:
Explanation: While dehydration can lead to decreased urine output, urinary frequency is not a typical complication of vomiting. Dehydration often results in decreased urine production.

D. Peripheral edema:
Explanation: Peripheral edema is not a direct complication of vomiting. It is more commonly associated with conditions such as heart failure or renal issues.

A. Bradycardia B. Flushed skin C. Decreased appetite D. Tremors

Correct Answer is D

No explanation

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A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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