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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Nutrisystems is a commercial weight loss program that provides pre-packaged meals. While it may be effective for some, it is not directly sponsored by the USDA and might not align with the specific dietary recommendations promoted by the government for overall health.
Choice B rationale
MyPlate is a nutritional guide developed by the United States Department of Agriculture (USDA). It is designed to help Americans make healthier food choices by illustrating the five food groups and providing recommendations on portion sizes and a balanced diet. This is a direct resource sponsored by the USDA.
Choice C rationale
Weight Watchers (now WW) is a commercial weight loss program that utilizes a points system to guide food choices and encourages group support. While it can be a helpful resource for weight management, it is not a USDA-sponsored program.
Choice D rationale
eDiets.com is a commercial website that offers various diet plans, recipes, and fitness advice. While it may provide useful information for some individuals, it is not a resource directly sponsored or developed by the USDA.
Correct Answer is B
Explanation
Choice A rationale
Light palpation is typically performed after auscultation to assess for superficial tenderness, muscle tone, and pulsations. Auscultation precedes palpation to avoid inducing artificial bowel sounds or altering existing ones due to manual pressure.
Choice B rationale
Auscultation of bowel sounds in all four quadrants is the next step in the abdominal assessment after inspection. Listening to bowel sounds provides information about the motility of the gastrointestinal tract and should be done before palpation or percussion, which can alter these sounds.
Choice C rationale
Percussion for tones in all four quadrants is usually performed after auscultation and before palpation. Percussion helps to assess the size and density of abdominal organs and to identify the presence of fluid or air.
Choice D rationale
Deep palpation is performed last in the abdominal assessment sequence to evaluate for deeper masses and aortic pulsations. It follows inspection, auscultation, and light palpation, allowing the nurse to gather preliminary information before applying deeper pressure. .
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