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?

Assist the client to low Fowler's position.

Warm the feeding solution to body temperature.

Discard any residual gastric contents.

Test the pH of gastric aspirate.

Answer and Explanation

The Correct Answer is D

A. Assist the client to low Fowler's position:
Placing the client in a semi-upright or low Fowler's position during and after the feeding helps prevent aspiration and facilitates digestion. This position reduces the risk of regurgitation and reflux.

B. Warm the feeding solution to body temperature:
Ensuring the feeding solution is at room temperature or slightly warmer can enhance the client's comfort and reduce the risk of cramping or discomfort caused by cold fluids.

C. Discard any residual gastric contents:
Before initiating a new feeding, it's essential to check and discard any residual gastric contents from the previous feeding to prevent contamination, ensure accurate measurement, and minimize the risk of bacterial growth.

D. Test the pH of gastric aspirate:
Checking the pH of gastric aspirate is an important step to confirm the proper placement of the NG tube in the stomach. Gastric pH is typically acidic (pH less than 5), indicating the correct placement of the tube in the stomach rather than the respiratory tract, where the pH is higher (more alkaline).

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Correct Answer is C

Explanation

A. To confirm the placement of the NG tube:
Confirming NG tube placement is typically done using other methods, such as auscultation of air insufflation, pH testing, or X-ray. Gastric residual measurement helps assess the status of the stomach content but is not the primary method for confirming tube placement.

B. To determine the client's electrolyte balance:
While the gastric contents do contain electrolytes, the primary purpose of measuring gastric residual is to assess gastric emptying and potential feeding intolerance. It is not the most accurate method for determining overall electrolyte balance.

C. To identify delayed gastric emptying:
This is the correct and primary purpose. Measuring gastric residual helps in identifying if there's a delay in the stomach emptying the previously administered feeding, which can inform the nurse about the client's tolerance to enteral nutrition.

D. To remove gastric acid that might cause dyspepsia:
The process of measuring gastric residual doesn't involve removing gastric acid. It's more about assessing how much of the previously administered feeding remains in the stomach. If there's a high residual volume, it may suggest delayed emptying or feeding intolerance. The focus is on adjusting the feeding plan rather than removing gastric acid.

A. Reposition the client every 2 hr. B. Elevate the head of the client's bed 45° C. Massage the client's bony prominences. D. Provide the client with a high-calorie diet.

Correct Answer is A

Explanation

A. Reposition the client every 2hr:
Regular repositioning helps redistribute pressure and prevent tissue damage. Turning the client every 2 hours is even better, especially for those at higher risk.

B. Elevate the head of the client's bed 45°:
Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.

C. Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.

D. Provide the client with a high-calorie diet:
While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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