A nurse is caring for a patient who receives intermittent enteral feedings through an NG tube.
Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
To determine the patient’s electrolyte balance
To confirm the placement of the NG tube
To remove gastric acid that might cause dyspepsia
To identify delayed gastric emptying
The Correct Answer is D
Choice A rationale
While electrolyte balance is important in patient care, it is not the primary reason for measuring gastric residual before administering a feeding through an NG tube.
Choice B rationale
Confirming the placement of the NG tube is crucial before administering a feeding. However, measuring the gastric residual is not the primary method used to confirm tube placement.
Choice C rationale
Removing gastric acid that might cause dyspepsia is not the main purpose of measuring gastric residual. Dyspepsia, or indigestion, is typically managed with medications and dietary modifications.
Choice D rationale
The primary purpose of measuring gastric residual is to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. If gastric emptying is delayed, the nurse should avoid overfeeding the patient and causing gastric distention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Irrigating the nasogastric tube with tap water is not recommended. Tap water is not sterile and can introduce bacteria into the stomach, potentially causing infection.
Choice B rationale
Marking abdominal girth once daily is not sufficient for a client who is postoperative following peritoneal lavage for peritonitis. This client is at risk for complications such as abscess formation and bowel obstruction, which can cause rapid changes in abdominal girth. Therefore, abdominal girth should be measured more frequently.
Choice C rationale
Placing the client in a high Fowler’s position is the correct intervention. This position, which involves the client sitting up at an angle of 45 to 60 degrees, can help reduce pressure on the abdominal area, promote better lung expansion, and facilitate drainage of gastric contents, thus reducing the risk of aspiration.
Choice D rationale
Ambulating the client twice daily is not appropriate in this case. The client has just undergone a major abdominal surgery and has a nasogastric tube and closed-suction drains in place. Early ambulation may not be feasible due to the risk of dislodging the drains or causing pain and discomfort.
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.
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