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 B
Explanation
B. This statement demonstrates an understanding of palliative care as a supportive approach focused on optimizing independence and quality of life. Palliative care emphasizes symptom management, psychosocial support, and enhancing functional abilities to enable patients to live as fully and independently as possible, even in the context of a progressive neurologic disease. This statement aligns with the principles of palliative care, which aim to empower patients to make choices and maintain control over their lives.
A. This statement reflects a perception of palliative care as solely placing the responsibility of care on the family. While family support is an essential component of palliative care, it is not the sole responsibility of the family. Palliative care aims to provide comprehensive support to patients with serious illnesses, addressing physical, emotional, social, and spiritual needs. It involves a collaborative approach involving healthcare professionals, patients, and their families to ensure holistic care and quality of life.
C. This statement suggests a misconception about palliative care, equating it with relinquishing control of care decisions to a partner or caregiver. In reality, palliative care emphasizes patient-centered decision-making and supports patients in expressing their preferences, values, and goals of care. While caregivers play an important role in the palliative care team, ultimate decision-making authority rests with the patient, and care plans are tailored to align with the patient's wishes and priorities.
D. This statement reflects a misunderstanding of palliative care as a replacement for disease-specific medical care, such as neurology. Palliative care is not mutually exclusive with disease-focused treatment but rather complements it by addressing the broader physical, emotional, and social needs of patients with serious illnesses, including progressive neurologic diseases. Palliative care can be provided concurrently with disease-specific treatments and involves a multidisciplinary team, which may include specialists like neurologists, to ensure comprehensive care.
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.
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