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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Performing hand hygiene frequently and consistently is the most effective way to prevent the spread of pathogens during patient care. Hand hygiene is the single most important measure to reduce the transmission of harmful germs and prevent health care-associated infections.
Choice B rationale
Properly disposing of contaminated equipment is important in preventing the spread of pathogens, but it is not the most effective measure. While it is crucial to handle and dispose of contaminated equipment properly, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice C rationale
Discarding used syringes in appropriate containers is a standard safety measure in healthcare settings, but it is not the most effective way to prevent the spread of pathogens during patient care. While it is important for preventing needlestick injuries and the spread of bloodborne pathogens, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice D rationale
Changing soiled linens daily for patients with draining wounds is a part of standard wound care and infection control, but it is not the most effective way to prevent the spread of pathogens during patient care. Hand hygiene remains the most effective measure in preventing the spread of pathogens.
Correct Answer is A
Explanation
Choice A rationale
Placing clean linen that touched the floor in the soiled linen bag is a correct practice. This is because the floor is considered dirty, and any linen that comes into contact with it should be considered contaminated.
Choice B rationale
Shaking soiled linen to remove any toilet paper remnants is not a correct practice. Shaking soiled linen can disperse pathogens into the air, increasing the risk of disease transmission.
Choice C rationale
Placing the soiled linen on the floor before bagging it is not a correct practice. Soiled linen should be handled as little as possible and placed directly into a designated, leak-proof container.
Choice D rationale
Holding the soiled linen against her body while carrying it to the linen bag is not a correct practice. Soiled linen should be handled carefully to avoid contact with the body, as this can lead to contamination of the worker’s clothing and potentially spread infection.
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