A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?
Measure the client's gastric residual before each feeding.
Change the bag and tubing every 24 hr.
Document intake and output.
Flush the tubing with 30 mL of water after each feeding.
The Correct Answer is A
The correct answer is Choice A - Measure the client's gastric residual before each feeding.
Choice A rationale:
The nurse's first action in caring for a client receiving intermittent enteral feedings should be to measure the client's gastric residual before each feeding. Gastric residual volume helps assess the client's tolerance to enteral feedings and can indicate delayed gastric emptying or potential complications like aspiration. If the residual volume is high, the nurse can collaborate with the healthcare team to determine whether to hold the feeding, adjust the feeding rate, or take other appropriate actions to ensure the client's safety and optimal nutritional status.
Choice B rationale:
Changing the enteral feeding bag and tubing every 24 hours is important to maintain the sterility and integrity of the feeding system. However, it is not the first action the nurse should take. The priority is to assess the client's tolerance to the feeding by measuring gastric residuals, which helps prevent complications.
Choice C rationale:
Documenting intake and output is a crucial aspect of nursing care for all clients, including those receiving enteral feedings. However, in the context of intermittent enteral feedings, measuring gastric residuals before each feeding is a more immediate and specific action to ensure the client's safety and well-being.
Choice D rationale:
Flushing the tubing with 30 mL of water after each feeding is important to prevent clogging and maintain the patency of the enteral feeding tube. However, this action is secondary to measuring gastric residuals, which directly assesses the client's tolerance to the feedings and helps prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice a. "It must be difficult facing this type of surgery.”
Choice A rationale: This statement acknowledges the client’s feelings and provides emotional support, which is crucial in reducing anxiety and promoting a sense of understanding and empathy.
Choice B rationale: While this statement aims to reassure the client, it may come off as dismissive of the client’s unique concerns and feelings, potentially making them feel invalidated.
Choice C rationale: Although this statement highlights the facility’s reputation, it does not directly address the client’s immediate emotional needs or concerns about the surgery.
Choice D rationale: Offering a sleeping pill addresses the symptom (inability to sleep) but does not address the underlying anxiety or emotional distress the client is experiencing. Emotional support is often more effective in such situations.
Correct Answer is B
Explanation
The correct answer is choice B. "Tighten your stomach muscles.” This is because when turning an immobile client in bed, it’s important to use proper body mechanics to prevent injury. Tightening the stomach muscles helps to stabilize the core, which supports the spine and can help prevent back strain.
Choice A rationale:
"Keep your feet close together” is wrong because having a wide base of support with the feet apart provides better balance and stability when turning a client in bed.
Choice C rationale:
"Straighten your knees” is wrong because you should keep your knees slightly bent to maintain balance and allow for a smooth transfer of weight as you turn the client.
Choice D rationale:
"Bend at your waist” is wrong because bending at the waist increases the risk of a back injury. It’s important to bend the knees and keep the back straight when leaning over to turn a client.
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