Enteral Feeding And Aspiration Risk
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NCLEX-PN › Enteral Feeding And Aspiration Risk
On a medical-surgical unit, a 73-year-old client with a recent stroke and dysphagia is receiving nasogastric tube feedings. The nurse hears coughing during the feeding and notes crackles in the posterior lung bases. What is the nurse’s PRIORITY action to prevent aspiration?
Increase the amount of free water flushes
Check blood glucose and administer insulin per sliding scale
Stop the feeding and elevate the head of the bed while assessing respiratory status
Document the findings and continue to monitor
Explanation
This question tests understanding of enteral feeding and aspiration risk in a client with dysphagia on nasogastric feedings. The priority framework is client safety through prevention of aspiration, responding to auditory cues. The correct answer, stopping the feeding and elevating the head of the bed while assessing respiratory status, is the best choice because it prevents further aspiration and allows lung sound evaluation. The distractors are incorrect because increasing water flushes doesn't address crackles, checking glucose is unrelated, and documenting without action delays care. The decision-making principle is to stop feedings upon hearing coughing or crackles. Elevation promotes drainage and breathing ease. A transferable strategy is to auscultate during feedings, pausing and repositioning if adventitious sounds appear.
Before administering an intermittent enteral feeding, the practical nurse (PN) aspirates 150 mL of gastric residual volume. The previous feeding was 250 mL. What is the most appropriate action for the PN to take?
Hold the feeding and notify the registered nurse (RN).
Administer the feeding as scheduled.
Re-instill the residual and recheck in 4 hours.
Dilute the formula with sterile water.
Explanation
A gastric residual volume (GRV) of 150 mL may indicate delayed gastric emptying, which places the client at risk for aspiration. The PN's scope of practice requires reporting this significant finding to the RN. The RN will then collaborate with the healthcare provider to determine the next steps. Administering the feeding, diluting the formula, or waiting 4 hours without notifying the RN would be unsafe.
The practical nurse (PN) is caring for a client with a gastrostomy tube. What is the most reliable method for the PN to use to confirm tube placement before administering medications and a bolus feeding?
Aspirating gastric contents and checking the pH.
Auscultating for a rushing sound over the epigastrium while injecting air.
Asking the client if they feel the tube is in the right place.
Measuring the external length of the tube.
Explanation
While an X-ray is the gold standard for initial placement verification, checking the pH of aspirated gastric contents is the most reliable bedside method for routine checks before each feeding. A pH of 5 or less is indicative of gastric placement. The air insufflation (whoosh test) is no longer considered reliable. Measuring the external length can help detect displacement, but it does not confirm tip placement. The client's sensation is not a reliable indicator.
Immediately after administering a bolus feeding through a nasogastric tube, what is the priority action for the practical nurse (PN)?
Flush the tube with 30-50 mL of water.
Clamp the tube and disconnect the syringe.
Position the client in a left side-lying position.
Remove the nasogastric tube.
Explanation
Flushing the tube with water after a feeding is essential to clear the formula from the tubing, prevent clogging, and provide the client with necessary hydration. The tube should remain clamped after flushing, and the client should remain in a semi-Fowler's position for at least 30-60 minutes to reduce aspiration risk. The tube should not be removed.
The practical nurse (PN) is reinforcing teaching for a family member who will be administering enteral feedings at home. Which statement by the family member indicates a need for further instruction?
"I will let my mother lie down flat to rest right after the feeding is done."
"I will flush the tube with water after the feeding is done."
"I will keep my mother's head elevated during and after the feeding."
"I will check for residual volume before each feeding."
Explanation
This statement indicates a misunderstanding of aspiration precautions. The client should remain with the head of the bed elevated for at least 30 to 60 minutes after an intermittent feeding to prevent reflux and aspiration. The other statements demonstrate correct understanding of the procedure.
The practical nurse (PN) is attempting to administer a bolus feeding, but the formula will not flow through the gastrostomy tube. What is the nurse's first action?
Instill a carbonated beverage to dissolve the clog.
Notify the RN that the tube needs to be replaced.
Attempt to flush the tube with warm water using a 60 mL syringe.
Use a small guidewire to clear the obstruction.
Explanation
The first step in managing a clogged tube is to attempt flushing with warm water using gentle pressure with a large syringe (30-60 mL) to avoid excessive pressure that could rupture the tube. Using a guidewire is dangerous and should never be done. Using carbonated beverages is not a consistently evidence-based practice and warm water should be tried first. The tube may not need replacement, so troubleshooting should occur before notifying the RN.
The practical nurse (PN) is preparing to administer a crushed medication through a nasogastric tube that is also used for enteral feedings. Which action is essential for client safety?
Mixing the crushed medication directly into the enteral formula.
Flushing the tube with water before and after administering the medication.
Crushing an enteric-coated tablet and dissolving it in water.
Using cold water to dissolve the medication to prevent clumping.
Explanation
To ensure the client receives the full dose and to maintain tube patency, the tube must be flushed with water (typically 15-30 mL) before giving the medication and flushed again after. This clears the tube of formula and ensures the medication is delivered to the stomach. Medications should not be mixed with formula due to potential incompatibilities. Enteric-coated tablets should never be crushed. Room temperature water is preferred for dissolving medications.
The practical nurse (PN) is collecting data on a client with a nasogastric tube for enteral feeding. Which finding should be reported to the registered nurse (RN) immediately?
The skin around the client's nares is dry.
A new onset of crackles auscultated in the lungs.
The client reports feeling hungry before the next feeding.
Gastric residual volume of 40 mL.
Explanation
New onset of crackles in the lungs is a significant finding that could indicate fluid in the lungs from aspiration of the feeding formula. This is a potential medical emergency that requires immediate reporting and intervention. The other findings are either normal or require routine intervention but are not urgent.
The practical nurse (PN) is planning care for a client receiving continuous enteral feedings via a gastrostomy tube. Which task can the PN delegate to an unlicensed assistive personnel (UAP)?
Flushing the gastrostomy tube with water.
Checking the gastric residual volume.
Administering a scheduled bolus feeding.
Reporting any client complaints of nausea.
Explanation
The UAP can be delegated the task of reporting client symptoms, such as complaints of nausea or discomfort, to the nurse. Administering feedings, checking residual volume, and flushing the tube are nursing procedures that require the knowledge and skill of a licensed nurse and cannot be delegated to a UAP.
The practical nurse (PN) is monitoring a client who started enteral feedings 8 hours ago. Which finding would suggest the client is not tolerating the feeding?
A soft, non-distended abdomen.
Presence of active bowel sounds in all four quadrants.
Reports of abdominal cramping and vomiting.
The client passing flatus.
Explanation
Abdominal cramping, distention, nausea, and vomiting are key signs of feeding intolerance. Active bowel sounds, a soft abdomen, and passing flatus are all indicators of normal gastrointestinal function and suggest the client is tolerating the feeding well.