A nurse is preparing to administer an enteral feeding via an established NG tube. Identify the sequence the nurse should follow to initiate the feeding.

(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Verify tube placement.

Check the residual feeding contents.

Administer the feeding.

Evaluate tolerance to the feeding.

Answer and Explanation

The Correct Answer is A,B,C,D

Choice A rationale

Verifying tube placement is the initial critical step to ensure the feeding is delivered into the gastrointestinal tract and not the respiratory system, thereby preventing aspiration. Methods for verification include pH testing of aspirate (target pH ≤ 5.5), and radiographic confirmation is the gold standard, especially after initial placement.

Choice B rationale

Checking the residual feeding contents before administering a new feeding is essential to assess the client's tolerance to the previous feeding and prevent overfeeding, which can lead to complications like abdominal distension, nausea, vomiting, and aspiration. A high residual volume may indicate delayed gastric emptying.

Choice C rationale

Administering the feeding follows confirmation of tube placement and assessment of residual volume. The feeding should be administered at the prescribed rate and volume, ensuring the client receives adequate nutrition and hydration. The client should be positioned with the head of the bed elevated at least 30-45 degrees during and for at least 30-60 minutes after feeding to minimize aspiration risk.

Choice D rationale

Evaluating the client's tolerance to the feeding is an ongoing process that involves monitoring for signs and symptoms such as abdominal distension, pain, nausea, vomiting, diarrhea, or aspiration. This evaluation helps determine if the feeding regimen needs adjustment in terms of rate, volume, or formula.

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Correct Answer is C

Explanation

Choice A rationale

Placing the client in a prone position is contraindicated during nasogastric tube insertion. This position does not facilitate the passage of the tube into the esophagus and can increase the risk of aspiration if the client were to vomit. The optimal position is high Fowler's, which utilizes gravity to aid tube advancement.

Choice B rationale

Measuring the nasogastric tube from the tip of the nose to the earlobe to the xiphoid process is the correct technique to estimate the length of the tube needed to reach the stomach. This method accounts for the distance from the nasal passage, down the pharynx and esophagus, to the stomach.

Choice C rationale

Instructing the client to place their chin to their chest and swallow helps to close the epiglottis, thereby preventing the nasogastric tube from entering the trachea and directing it towards the esophagus. Swallowing facilitates the downward movement of the tube with esophageal peristalsis.

Choice D rationale

Advancing the nasogastric tube quickly increases the client's discomfort and anxiety and elevates the risk of trauma to the nasal passages, pharynx, and esophagus. The tube should be advanced slowly and gently, allowing the client to swallow and cooperate during the procedure.

A. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth. B. Asymmetry of the breasts is common, but the nurse should verify that this finding is not new. C. Asymmetry of the breast is unusual, and the patient should be referred to a physician. D. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.

Correct Answer is B

Explanation

Choice A rationale

While a sudden and significant asymmetry in breast size or shape could indicate a new issue such as inflammation or a growth and warrants investigation, a slight, long-standing asymmetry is quite common among women. It does not automatically signify a pathological condition.

Choice B rationale

It is a well-established fact that many women have some degree of natural asymmetry in their breast size and shape. However, it is crucial for the nurse to ascertain if this finding is new for the patient. A recent change in asymmetry could be a sign of a developing condition that requires further evaluation.

Choice C rationale

While any new or significant asymmetry should be evaluated by a physician to rule out underlying issues, a long-standing, slight asymmetry is a common physiological variation and does not necessarily require immediate referral unless other concerning signs or symptoms are present.

Choice D rationale

Breastfeeding can sometimes cause temporary changes in breast size due to milk production and engorgement, and one breast might produce slightly more milk than the other. However, a noticeable and persistent asymmetry might predate breastfeeding or persist beyond it, and while it might be benign, attributing it solely to breastfeeding without further assessment of its history is not prudent. .

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A nurse is preparing to administer an enteral feeding via an established NG tube. Identify the sequence the nurse should follow to initiate the feeding. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

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Explanation

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Correct Answer is B

Explanation

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A nurse is preparing to administer an enteral feeding via an established NG tube. Identify the sequence the nurse should follow to initiate the feeding.

(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)