A nurse is caring for a patient receiving enteral nutrition through a nasogastric tube. Which interventions should the nurse implement to ensure safe and effective enteral feeding?
(Select All that Apply.)
Position the patient supine during feeding to enhance comfort.
Monitor gastric residual volumes regularly.
Administer all feedings rapidly to decrease procedure time.
Use sterile gloves when handling the feeding tube.
Flush the tube with water before and after medication administration.
Elevate the head of the bed to at least 30 degrees during feeding.
Verify tube placement before starting the feeding.
Correct Answer : B,E,F,G
A. Positioning the patient supine can increase the risk of aspiration and should be avoided during feeding. The head of the bed should be elevated instead.
B. Monitoring gastric residual volumes is important to assess the tolerance of the feeding and prevent aspiration.
C. Feedings should be given slowly to avoid complications like gastric distention, not rapidly.
D. Using sterile gloves when handling a feeding tube is not necessary unless there is a risk for infection, but clean gloves are generally adequate.
E. Flushing the tube with water before and after medication administration helps to maintain patency and prevent clogging.
F. The head of the bed should be elevated at least 30 degrees during feeding to reduce the risk of aspiration.
G. Verifying tube placement before starting the feeding ensures that the feeding is going into the stomach and not the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Documenting the seizure activity is important but should be done after addressing immediate needs.
B. Checking the patient's vital signs is important but is secondary to positioning the patient safely to prevent aspiration.
C. Administering oral antiepileptic medication is necessary but not the first action following a tonic- clonic seizure.
D. Placing the patient in a side-lying position immediately after the seizure ensures that the airway remains open and reduces the risk of aspiration.
Correct Answer is D
Explanation
A. Klebsiella pneumoniae is a Gram-negative bacterium and is typically associated with more severe pneumonia, particularly in patients with underlying lung disease, but it does not form clusters.
B. Streptococcus pneumoniae is a common cause of pneumonia but typically appears as Gram-positive cocci in pairs or chains, not clusters.
C. Escherichia coli is a Gram-negative bacterium that generally causes urinary tract infections and is not a common cause of pneumonia with Gram-positive cocci in clusters.
D. Staphylococcus aureus is a Gram-positive bacterium that forms clusters and is a common cause of pneumonia, particularly in young, otherwise healthy individuals, and can present with fever, chills, and productive cough. This fits the presentation and sputum findings in this patient.
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