A nurse is assessing a client who is receiving intermittent tube feedings. Which of the following actions should the nurse take to reduce the risk of aspiration when administering the tube feeding?
Verify the tube placement with x-ray prior to initial use.
Check the gastric residual every 2 hr.
Stop feeding if gastric residual is greater than 100 mL.
Place client in the Trendelenburg position.
The Correct Answer is A
A. Verify the tube placement with x-ray prior to initial use: Confirming NG or feeding tube placement via radiography is the gold standard before the first feeding. Proper tube positioning in the stomach or small intestine prevents inadvertent pulmonary placement, which is the primary cause of aspiration and serious respiratory complications.
B. Check the gastric residual every 2 hr: Monitoring gastric residuals can help assess tolerance of enteral feeding, but routine checks every 2 hours are not universally required and do not prevent aspiration if the tube is misplaced. Residual checks are adjunctive safety measures rather than primary preventive actions.
C. Stop feeding if gastric residual is greater than 100 mL: Guidelines for holding feedings based on residual volume vary, and a cutoff of 100 mL is not standardized. While excessive residuals may increase aspiration risk, withholding feeding alone does not prevent aspiration if tube placement has not been verified.
D. Place client in the Trendelenburg position: Trendelenburg (head-down) position increases the risk of reflux and aspiration during tube feeding. The appropriate position is upright (30–45°) to facilitate gastric emptying and reduce the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","F"]
Explanation
A. "I should notify my provider before taking any new over-the-counter or prescription medications.": Many anti-tuberculosis medications, such as rifampin and isoniazid, have significant drug-drug interactions. Rifampin is a potent cytochrome P450 inducer, which can alter the metabolism of other medications, potentially reducing their effectiveness or increasing toxicity. Notifying the provider ensures safe co-administration and prevents adverse effects.
B. "I can expect my contact lenses to turn red or orange.": Rifampin can cause harmless discoloration of body fluids, including tears and saliva, which may stain contact lenses orange-red. This is an expected effect of therapy and does not indicate harm or require discontinuation, but the client should be educated to avoid alarm.
C. "I will need to take my medications for a total of 5 weeks.": Tuberculosis treatment requires a prolonged course, typically 6 months or longer, depending on the regimen. A 5-week duration is insufficient for eradication and increases the risk of drug resistance. This statement indicates misunderstanding of therapy duration.
D. "I should decrease my alcohol intake to one to two drinks per day.": Alcohol should be completely avoided during anti-TB therapy, particularly with isoniazid and pyrazinamide, due to increased risk of hepatotoxicity. Suggesting a partial reduction demonstrates misunderstanding of safe practices during treatment.
E. "I am no longer contagious.": The client is still considered contagious until sputum cultures are negative, usually after several weeks of effective therapy. Assuming non-contagious status prematurely could lead to inadvertent transmission.
F. "I will need to have someone observe me when I take my medication.": Directly Observed Therapy (DOT) is the recommended approach for TB treatment to ensure adherence and prevent drug resistance. Understanding the need for observation demonstrates accurate comprehension of safe treatment practices.
Correct Answer is B
Explanation
A. Identify emergency shelter locations: Locating emergency shelters is important for providing temporary safety and resources for affected individuals, but this step is secondary to activating the emergency response system. Shelter identification is part of coordinated disaster management that follows initial response activation.
B. Activate the facility's emergency response system: The first action in any disaster response is to activate the emergency response system. This ensures that all necessary personnel, resources, and protocols are mobilized quickly to manage casualties, provide triage, and coordinate care efficiently. Immediate activation establishes the chain of command and enables a structured response to the evolving crisis.
C. Notify local service organizations and chaplains of the disaster: Notifying support services and chaplains is part of ongoing disaster management, offering emotional and logistical support. While important, it is not the initial priority because patient care and life-saving interventions take precedence.
D. Report the number of casualties to the Public Information Officer: Reporting casualty numbers helps manage public communication and coordination, but this step should occur after the emergency response system is activated and triage and critical care measures are underway. Immediate patient care and system activation take priority over reporting.
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