When preparing to administer medication via a nasogastric tube, the nurse aspirates 275 mL of gastric residual. What is the first action the nurse should take?
a. Wait 1 hour and recheck the residual.
b. Administer the medication with more fluid.
c. Return the aspirate and withhold the medication.
d. Attach the nasogastric tube to suction to remove additional volume.
C
Return aspirated contents to the stomach unless a single volume exceeds 500 mL or two measurements taken 1 hour apart each exceed 250 mL. When gastric residual is greater than 250 mL, the medication is withheld and the residual is rechecked in 1 hour. Large-volume aspirates indicate delayed gastric emptying and place the patient at risk for aspiration. Additional fluid would not be administered if the patient had a large residual. Use of suction would require an order from the health care provider.
You might also like to view...
The parents of an 8-year-old tell the nurse the child wakes the household crying out during his frequent nightmares. What is the nurse's most helpful response to explain nightmares?
a. They are a normal extension of the child's fear of mutilation. b. They are an abnormal response to repressed feelings. c. They are a common result of latent sexuality. d. They are a side effect of overactivity and stimulation.
The term uveitis is used to describe inflammation of which of the following? Select all that apply
a. Lens b. Cornea c. Retina d. Optic nerve e. Vitreous body f. Uveal tract of the eye, including iris, ciliary body, and choroid
The nurse is preparing to place a nasogastric tube in one of her patients. What is the process for determining the length of a nasogastric tube to be placed in the stomach?
A) Place distal tip to nose, then ear tip and end of xiphoid process. B) Instruct the patient to lie prone and measure tip of nose to umbilical area. C) Insert the tube into nose until tube fills with secretions. D) Obtain an order from the physician for the number of inches to insert the tube.
The stages of change identified in diffusion of innovation theory are:
a. contemplation, persuasion, action, and knowledge. b. knowledge, persuasion, decision, implementation, and confirmation. c. awareness, understanding, action, implementation, and confirmation. d. contemplation, decision, action, and knowledge.