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 C

Explanation

A. "The client's postoperative antibiotic was administered." While this information is important, it is not typically included in the change-of-shift report unless there were specific issues related to antibiotic administration (e.g., allergic reactions, missed doses).
B. "The client's partner came to visit today." While this information might be relevant to the client’s social and emotional well-being, it is not critical for the shift report regarding clinical care.
C. "At 2200, the client's IV fluid bag and tubing will need replacing." This statement is important for continuity of care and should be included in the report to ensure that the next shift is aware of necessary actions.
D. "Colonoscopy was performed 48 hours ago." This information is relevant for understanding the client’s postoperative status but is less immediate compared to other details such as current medication administration or upcoming needs.

A. Schedule a home visit in 3 weeks for weight and growth monitoring. B. Return to the primary health care provider in 3 days for a follow-up appointment. C. Cover the baby with a phototherapy blanket at home when sleeping. D. Return the baby for immunization in 1 month.

Correct Answer is B

Explanation

The correct answer is choiceB. Return to the primary health care provider in 3 days for a follow-up appointment.

Choice A rationale:

Scheduling a home visit in 3 weeks for weight and growth monitoring is not appropriate for a newborn who has recently been treated for jaundice.Close monitoring is essential to ensure that bilirubin levels do not rise again and to assess the baby’s overall health and feeding patterns.

Choice B rationale:

Returning to the primary health care provider in 3 days for a follow-up appointment is the most appropriate action.This allows for early detection of any rebound hyperbilirubinemia and ensures that the baby is feeding well and gaining weight appropriately.

Choice C rationale:

Covering the baby with a phototherapy blanket at home when sleeping is not recommended without medical supervision.Phototherapy should be administered under the guidance of healthcare professionals to monitor the baby’s bilirubin levels and ensure safety.

Choice D rationale:

Returning the baby for immunization in 1 month does not address the immediate need for follow-up care after jaundice treatment.Immunizations are important, but the priority is to monitor the baby’s bilirubin levels and overall health in the short term.

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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?

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Naxlex Comprehensive Predictor Exams

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