A nurse is caring for a client who is receiving continuous feedings via NG tube. Which of the following actions should the nurse take?

Irrigate the client's tube with 10 ml of cool water every hr

Elevate the head of the client's bed to a 15 angle

Replace the client's feeding bag every 72 hr

Check the client's gastric residual every 4 hr.

Answer and Explanation

The Correct Answer is D

A. Irrigate the client's tube with 10 ml of cool water every hr: Flushing an NG tube is appropriate to maintain patency, but 10 mL is often insufficient for continuous feedings, and routine irrigation “every hr” is not standard practice. Flushing should follow facility protocol and be based on feeding type, residuals, or signs of tube blockage.

B. Elevate the head of the client's bed to a 15 angle: Elevating the head of the bed only 15 degrees is insufficient to reduce the risk of aspiration during continuous enteral feeding. Evidence-based practice recommends elevating the head of the bed to 30–45 degrees to promote gastric emptying and prevent reflux or aspiration.

C. Replace the client's feeding bag every 72 hr: Feeding bags for continuous enteral feedings should be replaced more frequently, typically every 24 hours, to reduce bacterial contamination and the risk of infection. Waiting 72 hours increases the likelihood of microbial growth and potential sepsis.

D. Check the client's gastric residual every 4 hr: Monitoring gastric residuals every 4 hours is an important action to assess tolerance to continuous tube feeding. High residuals can indicate delayed gastric emptying or intolerance, guiding decisions to hold or adjust the feeding, preventing aspiration and other complications.

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Correct Answer is B

Explanation

A. Maintain client on bed rest: Strict bed rest is no longer routinely recommended for DVT unless complications arise. Early ambulation, if not contraindicated, can help prevent further clot formation and promote circulation. Prolonged immobilization may increase the risk of thrombus extension.

B. Elevate the client's affected extremity: Elevating the affected leg above heart level helps reduce venous pressure, swelling, and discomfort associated with DVT. This non-invasive intervention promotes venous return without increasing the risk of dislodging the thrombus, making it a safe and effective component of care.

C. Apply cold compresses to the client's affected extremity: Cold compresses are typically used for acute inflammation or localized trauma. In DVT, applying cold may not provide significant benefit and does not address the underlying venous obstruction or edema, so it is not routinely recommended.

D. Massage the muscle of the client's affected extremity: Massaging a limb with DVT is contraindicated because it can dislodge the thrombus, potentially causing a life-threatening pulmonary embolism. This action poses a high safety risk and must be strictly avoided.

A. A client who had an emergency appendectomy B. A client who had a vaginal hysterectomy C. A client who had a thyroidectomy D. A client who had cataract removal

Correct Answer is C

Explanation

A. A client who had an emergency appendectomy: While coughing can cause some discomfort at the abdominal incision site, it generally does not pose a high risk of serious complications if the client uses proper splinting techniques.

B. A client who had a vaginal hysterectomy: Coughing may cause mild discomfort or stress on the pelvic floor, but it is not typically associated with significant risk if the client follows postoperative instructions and uses support as needed.

C. A client who had a thyroidectomy: Coughing after a thyroidectomy can place stress on the surgical site in the neck, increasing the risk of bleeding, airway compromise, or wound dehiscence. This makes coughing a particular concern for immediate postoperative safety and monitoring.

D. A client who had cataract removal: Coughing does not pose a risk to the eye or surgical site following cataract surgery. Clients may be advised to avoid straining, but coughing is generally safe and not a priority concern.

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A nurse is caring for a client who is receiving continuous feedings via NG tube. Which of the following actions should the nurse take?

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