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 D
Explanation
Choice A rationale
Aspiration is not a common complication of TPN. TPN is administered intravenously, bypassing the gastrointestinal tract, which reduces the risk of aspiration. Choice B rationale
Polyuria, or excessive urination, is not typically a direct complication of TPN. However, the fluid balance of patients on TPN should be monitored, as both overhydration and dehydration can lead to urinary changes.
Choice C rationale
Stomatitis, or inflammation of the mouth and lips, is not a common complication of TPN. Since TPN bypasses the gastrointestinal tract, it does not typically cause oral complications.
Choice D rationale
Abdominal distention can occur as a complication of TPN. This is because TPN can cause an imbalance in the gut flora, leading to gas production and bloating. Additionally, if a patient on TPN has an underlying condition that affects gut motility, they may experience abdominal distention.
Correct Answer is B
Explanation
Choice A rationale
Airborne precautions are used for diseases that are spread by tiny droplets caused by coughing and sneezing. HIV is not spread through the air, so airborne precautions are not necessary.
Choice B rationale
Standard precautions are used for all patient care. They’re based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. HIV is transmitted by direct or indirect contact with infected blood or body fluids. Therefore, the nurse should plan to implement standard precautions when caring for this patient.
Choice C rationale
Droplet precautions are used for diseases that are spread by large droplets caused by coughing, sneezing, talking, or procedures such as suctioning and bronchoscopy. HIV is not spread through these methods, so droplet precautions are not necessary.
Choice D rationale
Contact precautions are used for diseases that are spread by direct contact with the patient or indirect contact with environmental surfaces or patient care items. HIV is not spread through casual contact, so contact precautions are not necessary.
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