A nurse is preparing to administer an intermittent enteral feeding through a small-bore NG tube. Which of the following actions should the nurse take before initiating the feeding?

Flush the tube with 5 mL of water.

Test the pH of fluid aspirated from the tube.

Inject air through the tubing and auscultate for gurgling sounds:

Change the bag and tubing system every 12 hr

Answer and Explanation

The Correct Answer is B

A. Flush the tube with 5 mL of water:

Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.

B. Test the pH of fluid aspirated from the tube (Correct Answer):

Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.

C. Inject air through the tubing and auscultate for gurgling sounds:

Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.

D. Change the bag and tubing system every 12 hr:

Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.

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Correct Answer is A

Explanation

A. Engage the client in a repetitive activity as a distraction:

This is the correct answer. Redirecting the client's focus to a repetitive and calming activity can help distract them from the source of agitation and potentially de-escalate the situation.

B. Place the client in a seclusion room:

Seclusion should only be used in situations where it is absolutely necessary for the safety of the client or others. Placing a client with dementia in seclusion is not the first choice and should be avoided if possible.

C. Apply wrist restraints to the client:

Restraints should be a last resort and used only when there is an imminent risk of harm to the client or others. Restraints can escalate agitation and should not be the initial response.

D. Administer PRN haloperidol IM to the client:

The use of medication should be considered later in the escalation process and after other non-pharmacological interventions have been attempted. It is not the first intervention, especially when there are non-pharmacological options available.

A. Identify current infection rates from facility data. B. Incorporate the process change into daily practice within the facility. C. Select a potential intervention to lower the current infection rate. D. Determine if the implemented change has lowered the current infection rate.

Correct Answer is A

Explanation

A. Identify current infection rates from facility data:

This is the correct answer. Before implementing any changes, it is crucial to assess the current state of infection rates within the facility. This data serves as a baseline to measure the effectiveness of interventions.

B. Incorporate the process change into daily practice within the facility:

This step comes after identifying the current infection rates. Implementing changes without understanding the baseline infection rates may not effectively address the issue.

C. Select a potential intervention to lower the current infection rate:

While selecting an intervention is a crucial step, it should follow the identification of current infection rates. Interventions should be evidence-based and tailored to the specific issues identified.

D. Determine if the implemented change has lowered the current infection rate:

This step occurs after the intervention has been implemented. It involves ongoing monitoring and evaluation to determine the impact of the changes on infection rates.

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A nurse is preparing to administer an intermittent enteral feeding through a small-bore NG tube. Which of the following actions should the nurse take before initiating the feeding?

Nursing Test Bank

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Explanation

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