The nurse places a nasogastric tube (NGT) as ordered by the physician.
When confirming placement, the nurse aspirates stomach contents and measures the gastric pH at 3. What should the nurse do next?

Choice A rationale

Verifying tube placement is the initial critical step to ensure the feeding is delivered into the gastrointestinal tract and not the respiratory system, thereby preventing aspiration. Methods for verification include pH testing of aspirate (target pH ≤ 5.5), and radiographic confirmation is the gold standard, especially after initial placement.

Choice B rationale

Checking the residual feeding contents before administering a new feeding is essential to assess the client's tolerance to the previous feeding and prevent overfeeding, which can lead to complications like abdominal distension, nausea, vomiting, and aspiration. A high residual volume may indicate delayed gastric emptying.

Choice C rationale

Administering the feeding follows confirmation of tube placement and assessment of residual volume. The feeding should be administered at the prescribed rate and volume, ensuring the client receives adequate nutrition and hydration. The client should be positioned with the head of the bed elevated at least 30-45 degrees during and for at least 30-60 minutes after feeding to minimize aspiration risk.

Choice D rationale

Evaluating the client's tolerance to the feeding is an ongoing process that involves monitoring for signs and symptoms such as abdominal distension, pain, nausea, vomiting, diarrhea, or aspiration. This evaluation helps determine if the feeding regimen needs adjustment in terms of rate, volume, or formula.

Choice A rationale

While prostate enlargement is common in older men, it is not typically directly associated with bilateral gynecomastia. Gynecomastia primarily involves breast tissue enlargement due to hormonal imbalances, not glandular changes related to the prostate. Recommending prostate screening solely based on gynecomastia is not the most direct or scientifically sound approach.

Choice B rationale

Acknowledging gynecomastia as benign breast enlargement without further investigation might be premature. While some cases in older men are benign and related to aging, it can also be a symptom of underlying medical conditions or medication side effects that require evaluation. Dismissing it without investigation could miss a treatable cause.

Choice C rationale

A mammogram is a screening tool for breast cancer, which is rare in men but possible. However, gynecomastia is characterized by benign glandular tissue proliferation, distinct from the tissue changes typically associated with male breast cancer. While a physician might order one to rule out malignancy, it's not the initial recommended action based solely on the finding of bilateral gynecomastia.

Choice D rationale

Gynecomastia in men can result from various hormonal changes, including a decrease in testosterone levels relative to estrogen, or an increase in estrogen production. Certain medical conditions and medications can also disrupt hormonal balance. Recommending a physician visit to investigate potential underlying causes of hormonal changes is the most appropriate initial action to determine the etiology of the gynecomastia and guide further management.