A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?
Label the feeding bag with the date and time of the start of the feeding.
Aspirate the client's stomach contents.
Hang the feeding bag 30 cm (12 inches) above the client.
Warm the feeding to room temperature.
The Correct Answer is B
Choice A reason:Labeling the feeding bag with the date and time is important for tracking, but it is not the first action to take. The priority is to ensure that the NG tube is correctly placed and the stomach contents can be aspirated to verify placement before administering the feeding.
Choice B reason:Aspirating the client's stomach contents is the first action the nurse should take. This is to confirm the correct placement of the NG tube to prevent complications such as aspiration pneumonia. It is a critical step before starting any enteral feeding.
Choice C reason: Hanging the feeding bag 30 cm (12 inches) above the client is necessary for gravity feeding, but it comes after verifying the NG tube placement through aspiration of stomach contents.
Choice D reason:Warming the feeding to room temperature is a comfort measure and helps to prevent gastrointestinal discomfort. However, it is not the first action to take. The priority is to check the tube placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
- Step 1: Identify the required dose in micrograms (mcg). The client is scheduled to receive 125 mcg of digoxin.
- Step 2: Identify the concentration of the available tablet. The available tablet contains 0.25 mg of digoxin.
- Step 3: Convert the tablet concentration from mg to mcg. We know that 1 mg = 1000 mcg. So, 0.25 mg = 0.25 × 1000 mcg = 250 mcg.
- Step 4: Calculate the number of tablets needed to deliver the required dose. We can set up a proportion to solve for this:
- 250 mcg is to 1 tablet as 125 mcg is to X tablets.
- In other words, 250 mcg : 1 tablet = 125 mcg : X tablets.
- Step 5: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 250 mcg × X tablets = 125 mcg × 1 tablet.
- Simplifying this gives us: 250X = 125.
- Dividing both sides by 250 gives us: X = 125 ÷ 250.
- Calculating the division gives us: X = 0.5.
So, the nurse should administer 0.5 tablets per dose to deliver the required dose of 125 mcg.
Correct Answer is A
Explanation
Choice A reason:Taping the connections on the client's chest tube is essential to maintain a closed system and prevent air leaks, which could lead to a pneumothorax.
Choice B reason:Positioning the client in a supine position is not recommended as it may not facilitate optimal drainage from the pleural space.
Choice C reason:Stripping the chest tube, which involves applying pressure and sliding the fingers down the tube to remove clots, is not routinely recommended as it can generate high negative pressures and damage lung tissue.
Choice D reason: The chest tube drainage system should be placed below the level of the client's heart to allow for gravity drainage of pleural fluid and air.
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