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 ["A","B","C"]
Explanation
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.
Correct Answer is D
Explanation
Choice A rationale
While it’s true that bulimia nervosa can have serious health consequences, telling the patient that they “should stop because they need to” may come across as dismissive of the patient’s struggle. It’s important to remember that bulimia nervosa is a complex mental health disorder that often requires professional treatment.
Choice B rationale
Asking the patient why they engage in their behavior might seem like a logical question, but it could potentially make the patient feel defensive or blamed for their condition. It’s important to approach the conversation with empathy and understanding.
Choice C rationale
While it’s important to validate the patient’s feelings and experiences, saying “I’m proud of you for recognizing that this behavior is not normal” might not be the most therapeutic response. This statement could potentially reinforce the idea that their behavior is “abnormal,” which could lead to feelings of shame or guilt.
Choice D rationale
Expressing empathy and understanding, as in “It seems like you are feeling helpless about this behavior,” can be a therapeutic response. This statement acknowledges the patient’s feelings and opens up the conversation for further exploration of their experiences and potential coping strategies.
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