The nurse is preparing to administer an enteral feeding to an ...

[skymedlock]

The nurse is preparing to administer an enteral feeding to an adult client with an indwelling feeding tube in place. Prior to administering the feeding, how will the nurse check placement of the tube? Select all that apply.
 
  Standard Text: Select all that apply. 1. X-ray
  2. Insert 10 cc of air into the tube while auscultating stomach.
  3. Check pH of aspirate.
  4. Assure effective gag reflex.
  5. Begin feeding slowly, and monitor client response.

Question 2

The nurse recognizes which of the following characteristics as normal development for the 18-month-old child? Standard Text: Select all that apply.
 
  1. Lumbar lordosis, protruding abdomen
  2. Rapid language development
  3. Words express thoughts.
  4. Can ride a tricycle.
  5. Can crawl down stairs.

[jsm54321]

Answer to Question 1

1,3,5
Rationale: While x-ray is not done prior to each feeding, it is the most effective means of assuring placement. It is usually done only after initial placement of the tube unless further confirmation is needed. Checking the pH of the aspirate might be helpful to determine if the tube is in the stomach, as pH should be 3-5, however, if the tube migrates into the bowel, pH will be alkaline, so this is not as effective as x-ray but is the best means of checking placement on a routine basis. Begin feedings slowly, and assess the client to minimize aspirate into the lungs, if there is a problem. Air insertion is highly inaccurate because a tube located high in the esophagus will still cause air to enter the stomach and could be very dangerous, leading to aspiration. Presence of the gag reflex is unrelated to checking placement.

Answer to Question 2

1,2,5
Rationale: Toddlers have a pronounced lumbar lordosis and protruding abdomen.

[skymedlock]

TYSM

[EAN94]

Gracias!