A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse is appropriate?
Checking residual volume before each feeding
Flushing the tube with 15 mL of water
Elevating the head of the bed to a 20" angle
Adding colored food dye to the formula
The Correct Answer is A
Rationale:
A. Checking residual volume prior to each feeding is appropriate to assess tolerance and reduce the risk of aspiration.
B. Flushing the tube should be done with at least 30 mL of water (not 15 mL) to maintain patency and prevent clogging.
C. The head of the bed should be elevated to at least 30° to 45°, not 20°, to reduce aspiration risk.
D. Adding food dye to formula is contraindicated due to the risk of adverse effects and is not evidence-based practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Administering an initial NG tube feeding requires assessment of tube placement and tolerance, which are nursing responsibilities—not within the AP’s scope.
B. Collecting a urine specimen is a routine, noninvasive task appropriate for delegation to an AP.
C. Checking a client’s pain level involves assessment, which cannot be delegated to an AP—it requires a licensed nurse.
D. Instructing a client about splinting an incision involves teaching, which is the nurse’s role, not the AP’s.
Correct Answer is A
Explanation
Rationale:
A. A client with emphysema and an oxygen saturation of 92% is stable and within an expected range for this condition. This client’s care can be appropriately managed by an LPN.
B. Admission assessments must be completed by an RN, not an LPN.
C. Administration of blood products (RBCs) requires an RN due to the need for close monitoring and rapid intervention for transfusion reactions.
D. Initiating oral nutrition after a stroke involves swallowing assessment and risk for aspiration, which must be performed by an RN.
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