The nurse is preparing to administer an enteral tube feeding to a client via a nasogastric tube. Which nursing action should be completed first?
Allow the formula to reach room temperature
Label feeding container with client's name and date/time hung
Aspirate stomach contents and check pH for tube placement
Assess residual volume
The Correct Answer is C
C. This is a critical initial step before administering enteral feedings. Aspirating stomach contents helps confirm the placement of the nasogastric tube in the stomach rather than the respiratory tract. Checking the pH of the aspirate can further confirm gastric placement, as gastric fluid typically has an acidic pH (usually less than 5). This step ensures that the feeding will be delivered to the correct location, minimizing the risk of aspiration.
A. While it's important for the formula to be at an appropriate temperature for administration to prevent discomfort or complications such as cramping, this is not typically the first action to take. It can be done concurrently with other preparatory steps.
B. Proper labeling of the feeding container is essential for patient safety and adherence to institutional policies. However, this is not the first action to be completed. It's usually done after preparing the feeding and confirming the tube placement.
D. Assessing residual volume involves checking for any residual contents in the stomach from previous feedings. This step helps determine how much of the previous feeding remains in the stomach and whether it's safe to administer the next feeding. However, it typically follows confirming tube placement, as it's essential to know the tube is in the correct position before assessing residual volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Directly asking the client how they learn best is a straightforward and effective approach for assessing their learning style preference. This allows the client to self-report their preferences, which can provide valuable insight into their preferred learning modalities, such as visual, auditory, or kinesthetic learning.
B. While assisting the client in learning skills from simple to complex can provide valuable information about their current level of understanding and skill mastery, it may not directly assess their learning style preference. This approach focuses more on the progression of learning rather than the client's preferred learning modalities.
C. Observing the client's interactions with others can provide some clues about their communication style and social preferences but may not necessarily directly assess their learning style preference. Learning style preference encompasses how individuals prefer to receive and process information, which may not be fully captured through social interactions alone.
D. Asking the client to read from a brochure primarily assesses their ability to process written information and may provide some insight into their literacy skills. However, it does not necessarily assess their preferred learning style, as individuals may have different preferences for how they prefer to receive and process information beyond reading.
Correct Answer is D
Explanation
D. Impaired immunity is a serious complication of prolonged stress that can have significant implications for overall health and susceptibility to illness. Chronic stress has been linked to dysregulation of the immune system, leading to decreased immune function and increased susceptibility to infections, autoimmune disorders, and other illnesses. Impaired immunity can compromise the body's ability to fight off pathogens and may contribute to the development or exacerbation of various health conditions.
A. Increased muscle tension is a common physiological response to stress but it is not typically considered a serious complication. Prolonged muscle tension can lead to discomfort, headaches, and musculoskeletal issues, but it is not usually life-threatening or associated with severe complications.
B. Altered sleep patterns, such as insomnia or disrupted sleep, can be significant consequences of prolonged stress. Chronic sleep disturbances can negatively impact physical health, cognitive function, and emotional well-being. While altered sleep patterns can have serious implications for overall health and quality of life, they are not typically considered life-threatening in the short term.
C. Increased peristalsis refers to heightened movement of the gastrointestinal tract, which can result in symptoms such as diarrhea or gastrointestinal discomfort. While gastrointestinal disturbances are common manifestations of stress, they are generally not considered the most serious complication of prolonged stress. However, severe or persistent gastrointestinal symptoms may warrant medical evaluation and management.
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