A tracheostomy patient is experiencing regurgitation of tube feeding formula. What should be the nurse's first priority?

Placing the patient in prone position to improve draining from mouth

Checking to make sure the tracheostomy cuff is inflated during tube feedings

Placing the patient in the right lateral decubitus position to promote gastric emptying

Discussing the use of metoclopramide to facilitate gastric motility with the practitioner

Answer and Explanation

The Correct Answer is B

A. The prone position is not recommended for managing tube feeding regurgitation, as it could lead to aspiration into the lungs.
B. The first priority is to ensure that the tracheostomy cuff is inflated during tube feedings to prevent aspiration and to ensure that the feeding is directed into the stomach and not into the airway.
C. The lateral decubitus position can help with gastric emptying, but the priority is to ensure proper cuff inflation to prevent aspiration.
D. While metoclopramide may help with gastric motility, the immediate concern is managing the risk of aspiration, which requires confirming cuff inflation.

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Correct Answer is D

Explanation

A. Fidelity refers to being loyal, faithful, and keeping promises, but it is not the primary principle when obtaining informed consent.
B. Nonmaleficence means "do no harm," which is important in healthcare but does not directly relate to the process of informed consent.
C. Beneficence involves promoting good and acting in the best interest of the patient but is secondary to ensuring informed consent is given.
D. Veracity is the ethical principle of truth-telling. It is most important when obtaining informed consent because the patient must fully understand the information about the procedure, including the risks and benefits, before giving consent.

A. Discontinue tube feeding and call the practitioner for parenteral nutrition orders B. Stop the tube feeding, wait 1 hour, and recheck the residual C. Continue the tube feeding and place the patient in the left lateral decubitus position to facilitate gastric emptying D. Continue the tube feeding if no other gastrointestinal symptoms exist and reassess the patient with the next residual check

Correct Answer is B

Explanation

A. Discontinuing the tube feeding and transitioning to parenteral nutrition is not the first action, as the residual volume may be manageable with additional interventions.
B. A residual volume of 200 mL is above the usual threshold, so the nurse should stop the feeding, wait, and recheck the residual to assess if it improves.
C. While positioning can help gastric emptying, the immediate action should be to stop the feeding and reassess before continuing.
D. Continuing the feeding without rechecking the residual volume would be premature, as the volume is higher than expected, potentially increasing the risk of aspiration.

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A tracheostomy patient is experiencing regurgitation of tube feeding formula. What should be the nurse's first priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which ethical principle is most important when soliciting informed consent from a patient?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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