A patient is receiving an enteral feeding at 65 mL/h. The GRV in 4 hours was 125 mL. What is the priority nursing intervention?
Assess bowel sounds.
Raise the head of the bed to at least 45 degrees.
Continue the feedings; this is normal gastric residual for this feeding.
Hold the feeding until you talk to the primary care provider.
The Correct Answer is C
Gastric residual volume (GRV) is measured to help assess gastric emptying and aspiration risk in patients on enteral feeding. Interpretation depends on the facility’s protocol and accepted thresholds; small residuals are usually acceptable and do not require stopping the feed.
Rationale for correct answer:
3. Continue the feedings; this is normal gastric residual for this feeding: Most clinical protocols consider a GRV of <200–250 mL acceptable and do not require holding feeds.
Rationale for incorrect answers:
1. Assess bowel sounds: Reasonable if you suspect intolerance, but with a GRV of 125 mL (which is below common stop thresholds), immediate assessment of bowel sounds is not the priority action.
2. Raise the head of the bed to at least 45 degrees: Always keep the HOB elevated during enteral feeding to reduce aspiration risk; if not already elevated this is important, but it is not the priority response to a normal GRV of 125 mL.
4. Hold the feeding until you talk to the primary care provider: Not necessary for this residual value and may interrupt nutrition unnecessarily; hold-and-report is usually reserved for higher residuals or signs of intolerance.
Take home points:
- GRV threshold - common thresholds: 200–250 mL
- Always keep the head of bed elevated during feedings, monitor for signs of intolerance (abdomen distension, vomiting, aspiration)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Parenteral nutrition (PN) is a specialized method of providing nutrition for clients who cannot use their gastrointestinal tract due to disease, surgery, or dysfunction. Unlike enteral nutrition, which delivers nutrients directly into the stomach or intestines, parenteral nutrition bypasses the digestive system completely.
Rationale for correct answer:
2. Intravenous access: Parenteral nutrition is administered directly into the bloodstream, most often via a central venous catheter (total parenteral nutrition, TPN) or sometimes through peripheral veins (peripheral parenteral nutrition, PPN).
Rationale for incorrect answers:
1. Gastrostomy tube: A gastrostomy tube delivers nutrition directly into the stomach through a surgically created opening. This is an example of enteral nutrition, not parenteral nutrition.
3. Nasogastric tube: A nasogastric tube passes through the nose into the stomach for feeding. This also represents enteral nutrition.
4. Jejunostomy tube: A jejunostomy tube delivers nutrition into the jejunum, another method of enteral feeding, not parenteral.
Take home points:
- Parenteral nutrition always uses intravenous access-not the GI tract.
- PN is reserved for clients with impaired GI function when enteral feeding is not possible or contraindicated.
Correct Answer is D
Explanation
Patients with dysphagia are at high risk for aspiration. When a patient being fed suddenly chokes, the immediate priority is to stop the offending activity so nothing more enters the airway and you can assess and manage the airway.
Rationale for correct answer:
4. Stop feeding her: Stopping the feeding immediately prevents additional material entering the airway and allows you to quickly assess the patient, call for help if needed, and institute airway-clearance measures.
Rationale for incorrect answers:
1. Suction her mouth and throat: May be needed if secretions or visible food are present and the patient cannot clear them, but suctioning is secondary to first stopping the feed and assessing the airway/level of obstruction.
2. Turn her on her side: Turning to the side helps drain secretions and reduces risk of aspiration into the lungs (useful after stopping the feed), but it is not the first immediate action.
3. Put on oxygen at 2 L nasal cannula: Oxygen can help if the patient becomes hypoxic, but oxygen does not remove an obstruction. Do not delay airway clearance to apply oxygen.
Take home points:
- Immediately stop the feed at the first sign of choking.
- Then assess airway, breathing, and level of consciousness and act (encourage cough, Heimlich, suction, or CPR) according to the patient’s response.
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