A nurse is caring for a patient in a long-term care facility who is receiving enteral feedings via an NG tube.
Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply)
Auscultate stomach sounds
Warm the formula to body temperature
Assist the client to sit in an upright position
Discard residual gastric contents
Correct Answer : A,B,C
Choice A rationale
Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.
Choice B rationale
Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.
Choice C rationale
Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.
Choice D rationale
Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
A decrease in systolic blood pressure is not a physiological change that increases the risk of dehydration in older adults.
Choice B rationale
An increase in saliva production does not occur with aging and does not increase the risk of dehydration.
Choice C rationale
An increase in the percentage of body water does not occur with aging. In fact, total body water decreases with age, which can contribute to an increased risk of dehydration.
Choice D rationale
A decrease in kidney function is a common physiological change that occurs with aging. This can lead to a decreased ability to concentrate urine and conserve water, increasing the risk of dehydration.
Correct Answer is D
Explanation
Choice A rationale
Broth is a clear liquid that can help replace sodium and chloride lost through diarrhea. However, it does not contain the necessary amounts of other electrolytes such as potassium and bicarbonate, which are also commonly lost in diarrhea.
Choice B rationale
Apple juice is not a good choice for a child with acute diarrhea. It is high in sugars and can worsen diarrhea. It also does not contain the electrolytes needed to replace those lost through diarrhea.
Choice C rationale
Cherry gelatin is not a suitable choice. While it is a clear liquid that can help with hydration, it does not contain the necessary electrolytes to replace those lost through diarrhea. It is also high in sugars, which can worsen diarrhea.
Choice D rationale
Pedialyte is the best choice for a child with acute diarrhea who reports that he is thirsty. It is a rehydration solution specifically designed to replace fluids and electrolytes lost through diarrhea.
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