A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next?

Question

Quizplus · Accepted Answer

11ecbb05_cb84_2b8c_b433_09885e021f7b_MD0009_00 Before administering intermittent (bolus) enteral feedings, the nurse must verify tube placement, such as with x-ray confirmation or gastric pH measurement. Ensuring that the tip of the feeding tube is correctly placed in the stomach or small intestine is essential because administration of enteral feeding through a misplaced tube may result in life-threatening aspiration (Option A). (Option B) Gastric residual volume (GRV) is one indicator of how well the client is tolerating enteral feedings. High GRV (eg, >500 mL) may indicate delayed gastric emptying and poor intestinal motility (ie, feeding intolerance), which is traditionally considered a risk factor for aspiration. The nurse should follow facility policy or contact the health care provider (HCP) to determine if feedings should be delayed for high GRV or other symptoms of intolerance (eg, gastric distension, nausea/vomiting). GRVs are traditionally checked every 4 hours with continuous feeding or before each intermittent feeding. However, some facilities no longer routinely check GRVs because recent evidence shows that this practice impairs calorie delivery and may be ineffective for predicting aspiration risk. (Option C) Repeatedly discarding gastric contents can cause hypokalemia and metabolic alkalosis. If GRV is excessively high, contents may be discarded to relieve abdominal distension (per facility policy or HCP prescription). However, GRV of 80 mL is not excessive and should be returned to the stomach. (Option D) Tube placement must be verified before enteral feedings. Educational objective: Before administering enteral feedings, the nurse must verify tube placement (eg, gastric pH measurement). Administration of enteral feeding through a misplaced feeding tube may result in life-threatening aspiration.

A Nurse Prepares to Administer an Intermittent Enteral Feeding Via