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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Confidentiality refers to the ethical duty of healthcare providers to safeguard patient information and maintain privacy. Upholding confidentiality means that healthcare providers must not disclose sensitive information about a patient to unauthorized individuals without the patient's consent. In this scenario, if the client asks the nurse not to disclose their medical diagnosis to their family members, respecting this request would uphold the principle of confidentiality by protecting the privacy of the patient's health information.
B. Justice in healthcare refers to the fair and equitable distribution of resources and the provision of healthcare services. While justice is an important ethical principle, it is not directly applicable to the client's request regarding the disclosure of their medical diagnosis to their family members.
C. Veracity, also known as truthfulness, is the ethical principle of honesty and truthfulness in communication with patients. Upholding veracity means providing patients with accurate and truthful information about their health condition and treatment options. In this scenario, if the nurse complies with the client's request not to disclose their medical diagnosis to their family members, it may involve withholding information and not fully disclosing the truth to the family members. Therefore, upholding the client's request may conflict with the principle of veracity.
D. A healthcare proxy is a legal document that allows an individual (the proxy) to make healthcare decisions on behalf of another person (the principal) if the principal is unable to make decisions for themselves. The existence of a healthcare proxy does not directly relate to the client's request regarding the disclosure of their medical diagnosis to their family members.

A. decreases pain tolerance. B. increases blood pressure. C. helps cope with stress. D. restores mind and body. E. helps conserve energy.

Correct Answer is ["C","D","E"]

Explanation

C. Sleep plays a crucial role in stress management and resilience. Adequate sleep helps regulate stress hormones such as cortisol, promotes emotional regulation, and enhances coping mechanisms. Chronic sleep deprivation can lead to increased stress levels and reduced ability to cope with stressors.
D. Sleep is essential for the restoration and repair of both the mind and body. During sleep, the body undergoes processes such as tissue repair, muscle growth, and memory consolidation. Sleep also allows the brain to clear toxins and waste products accumulated during wakefulness, promoting cognitive function and overall well-being.

E. One of the functions of sleep is to conserve energy. During sleep, metabolic rate and energy expenditure decrease, allowing the body to conserve resources for essential physiological processes. Sleep helps replenish energy stores, repair cellular damage, and prepare the body for the next day's activities.
A. Sleep has been shown to have analgesic effects and can improve pain tolerance. Adequate sleep helps reduce the perception of pain and promotes the release of endogenous pain-relieving substances in the body.
B. During sleep, blood pressure typically decreases as part of the normal sleep-wake cycle. However, certain sleep disorders, such as sleep apnea, may lead to fluctuations in blood pressure during sleep. Overall, quality sleep is important for maintaining cardiovascular health and regulating blood pressure.

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The nurse is preparing to administer an enteral tube feeding to a client via a nasogastric tube. Which nursing action should be completed first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client asks the nurse not to tell the family about the medical diagnosis. In meeting this request, the nurse would be upholding which of the following?

Correct Answer is A

Explanation

The nurse promotes good quality sleep for their clients based on the knowledge that sleep: (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

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