A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. (Move the steps, placing them in the selected order of performance. All steps must be used.)
Verify tube placement
Check the residual feeding contents
Evaluate tolerance of feeding
Administer the feeding
The Correct Answer is A,B,D,C
A. Verify tube placement: This is the first step to ensure that the tube is in the correct position and not in the lungs, which could lead to aspiration.
B. Check the residual feeding contents: This helps to assess gastric emptying and ensure that the stomach can tolerate the feeding. If there is a large amount of residual, the feeding may be delayed or the rate may need to be adjusted.
D. Administer the feeding: Once tube placement is confirmed and residual contents are assessed, the feeding can be administered at the prescribed rate.
C. Evaluate tolerance of feeding: After the feeding is complete, it's important to monitor the client for signs of tolerance, such as the absence of nausea, vomiting, or abdominal distension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Consuming hot cocoa, especially if it contains caffeine or sugar, is generally not advisable before bedtime. Caffeine is a stimulant that can interfere with the ability to fall asleep, and sugar can lead to disruptions in sleep. Even if the hot cocoa is caffeine-free, having a liquid right before bed can cause frequent awakenings during the night.
B. Alcohol can initially make a person feel drowsy, but it often disrupts sleep patterns later in the night, leading to poorer quality sleep. Reducing or eliminating alcohol consumption before bedtime can improve sleep quality and promote better rest.
C. While regular physical activity is beneficial for sleep, exercising too close to bedtime can actually be stimulating and make it harder to fall asleep. It is generally recommended to complete vigorous exercise at least 2-3 hours before going to bed to avoid interfering with sleep.
D. Muscle relaxation techniques, such as progressive muscle relaxation, are effective for reducing stress and improving sleep quality. However, performing these techniques in the afternoon is less beneficial compared to doing them closer to bedtime.
Correct Answer is A
Explanation
A. Checking the stockings for wrinkles is an important action. Wrinkles or folds in the stockings can create areas of increased pressure, which might lead to discomfort or skin breakdown and reduce the effectiveness of the stockings in preventing DVT. Ensuring that the stockings are smooth and free from wrinkles helps maintain proper compression and comfort.
B. Measuring the size of the client's foot is not typically required for properly fitting antiembolic stockings. The key measurements for antiembolic stockings are usually related to the calf, thigh, and sometimes the knee, not the foot.
C. Removing the stockings once each day is not usually recommended unless specifically instructed by a healthcare provider. Antiembolic stockings are generally worn continuously throughout the day and removed only for specific reasons, such as skin assessment or hygiene.
D. Applying the stockings while the client is sitting in a chair is not the preferred method. Antiembolic stockings should be applied while the client is lying down or in a supine position. This helps ensure that the stockings are applied evenly and that they provide consistent compression without causing undue pressure or discomfort.
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