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
Dark-colored urine is a common symptom of dehydration. When a person is dehydrated, their kidneys try to conserve water by concentrating the urine, which can make it appear darker. Choice B rationale
High blood pressure is not typically associated with dehydration. In fact, dehydration can sometimes lead to low blood pressure due to a decrease in blood volume.
Choice C rationale
Distended neck veins are not typically a symptom of dehydration. They are more commonly associated with conditions that cause fluid overload, such as heart failure.
Choice D rationale
Moist skin is not typically a symptom of dehydration. In fact, one of the symptoms of severe dehydration can be dry, cool skin.
Correct Answer is B
Explanation
Choice A rationale
Skin pallor and cool-to-touch skin are common signs of severe dehydration. When the body is severely dehydrated, blood flow to the skin decreases, causing the skin to feel cool and look pale.
Choice B rationale
Pitting edema is not a clinical finding of severe dehydration. In fact, it’s quite the opposite. Pitting edema is a condition that causes swelling due to fluid accumulation, often due to conditions like heart failure, liver disease, or kidney disease.
Choice C rationale
Tachycardia with a thready pulse is a common sign of severe dehydration. The heart rate increases in an attempt to maintain blood flow to the organs, and the pulse may feel weak or thready due to low blood volume.
Choice D rationale
Lung sounds diminished with crackles upon auscultation is not typically associated with dehydration. This is more commonly seen in conditions affecting the lungs such as pneumonia or heart failure.
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