A nurse is caring for a client in a geriatric unit.

Exhibits

For each client finding below, indicate if the finding is a best practice for managing enteral feeding tube safety or potential risk. Each finding may be associated with more than one category.

Ignoring cuff pressure during feeding

Checking tube placement before each feeding

Head of bed elevation at 30 degrees

Monitoring for signs of aspiration

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Rationale:

Ignoring cuff pressure during feeding: Failure to monitor cuff pressure can increase the risk of aspiration or injury to the trachea if the cuff is underinflated or overinflated. Maintaining appropriate cuff pressure is critical for airway protection in clients with feeding tubes.
Checking tube placement before each feeding: Verifying placement reduces the risk of feeding into the lungs, preventing aspiration and ensuring proper nutrition delivery.
Head of bed elevation at 30 degrees: Maintaining the head of the bed elevated decreases the likelihood of reflux and aspiration, which is essential for enteral feeding safety.
Monitoring for signs of aspiration: Observing for coughing, choking, or changes in respiratory status allows early intervention to prevent respiratory complications during tube feeding.

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Correct Answer is A

Explanation

A. Test the pH of gastric aspirate: Verifying tube placement before administering an enteral feeding is essential for client safety. Testing gastric aspirate for a pH of 1 to 5 confirms that the tube is in the stomach, reducing the risk of aspiration from misplaced feeding.

B. Place the client in low Fowler's position: Low Fowler’s position increases the risk of aspiration. The client should instead be positioned in high Fowler’s or at least 30–45 degrees during and after feeding to promote safe digestion and airway protection.

C. Warm the feeding solution to body temperature: Feeding solutions should be at room temperature to reduce the risk of cramping or diarrhea. Warming to body temperature is unnecessary and could encourage bacterial growth if improperly heated.

D. Discard any residual gastric contents: Residual contents should be measured, documented, and returned to the stomach unless volumes are excessive. Discarding residuals unnecessarily can cause electrolyte imbalances and disrupt nutrient delivery.

A. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." B. Clients over the age of 65 must have a saline lock according to facility policy." C. "It is quicker to administer medications intravenously in the hospital." D. "We administer all medications intravenously to clients in this unit.

Correct Answer is A

Explanation

A. "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours.": This response directly explains the medical reason for the saline lock, linking it to the client’s prescribed therapy. It provides clarity and reinforces that the intervention is necessary for safe and effective treatment.

B. "Clients over the age of 65 must have a saline lock according to facility policy.": Age alone is not a valid reason for IV access. Using such an explanation could reduce trust between the nurse and the client.

C. "It is quicker to administer medications intravenously in the hospital.": While IV administration can be faster, this response is vague and does not address why this particular client specifically requires a saline lock. It lacks individualized rationale.

D. "We administer all medications intravenously to clients in this unit.": Not all medications are given intravenously. Providing this explanation would confuse the client and reflect poor communication of actual care needs.

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A nurse is caring for a client in a geriatric unit. Exhibits For each client finding below, indicate if the finding is a best practice for managing enteral feeding tube safety or potential risk. Each finding may be associated with more than one category.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client in a geriatric unit.

Exhibits

For each client finding below, indicate if the finding is a best practice for managing enteral feeding tube safety or potential risk. Each finding may be associated with more than one category.