A nurse is managing nutrition for a client who is receiving intermittent enteral feedings through a nasogastric tube. Which of the following actions should the nurse take first?

Draw up the formula into a syringe.

Determine the pH level of gastric contents.

Flush the nasogastric tube with 30 mL of water.

Measure the total volume of gastric residual.

Answer and Explanation

The Correct Answer is B

A. Draw up the formula into a syringe. This step is premature and should be done after confirming the tube placement and checking for residual volume.
B. Determine the pH level of gastric contents. Checking the pH level of gastric contents helps confirm the placement of the nasogastric tube in the stomach, which is crucial before administering feedings or medications to prevent aspiration.
C. Flush the nasogastric tube with 30 mL of water. Flushing is important but should be done after confirming tube placement.
D. Measure the total volume of gastric residual. Measuring residual volume is important but should be done after confirming tube placement.

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Correct Answer is D

Explanation

A. Plan to initiate a bladder retraining program for the client. This is important but not the immediate first action.
B. Protect the client's perineal skin with a moisture barrier. This is a preventive measure but not the first step in evidence-based practice.
C. Teach the client to perform pelvic floor muscle exercises. This is useful but not the immediate first action.
D. Request a prescription for catheter removal. Indwelling urinary catheters should be removed as soon as possible to reduce the risk of infection, which aligns with evidence-based practice.

A. A decrease in skinfold thickness B. A triglyceride level of 150 mg/dL C. A random blood glucose reading of 160 mg/dL D. A mole that, is dark in color and tender

Correct Answer is D

Explanation

A. A decrease in skinfold thickness: A decrease in skinfold thickness could be due to loss of subcutaneous fat, which might not be immediately concerning without other symptoms.
B. A triglyceride level of 150 mg/dL: A triglyceride level of 150 mg/dL is generally considered within normal limits.
C. A random blood glucose reading of 160 mg/dL: A random blood glucose reading of 160 mg/dL is elevated and could indicate impaired glucose tolerance, warranting further investigation.
D. A mole that is dark in color and tender: A dark, tender mole could be a sign of a potentially malignant melanoma and should be evaluated by a provider for further investigation and potential biopsy.

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A nurse is managing nutrition for a client who is receiving intermittent enteral feedings through a nasogastric tube. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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