A nurse is providing care for a client who has dysphagia secondary to a stroke. The client has recently begun continuous tube feedings in order to meet his nutritional needs

Question

The nurse has assessed the client's gastric residual as ordered and identified a gastric residual volume of 210 ml. How should the nurse follow up this finding? A) Administer an additional 90 to 140 ml of feeding formula.
B) Instill 60 to 120 ml of sterile water to dilute the stomach contents.
C) Dilute the feedings by 50% with tap water for the next 6 hours.
D) Stop the feed until the client's gastric residual is less than 100 ml.

Answer 1

D
Feedback:
As a rule of thumb, the gastric residual should be no more than 100 ml or no more than 20% of the previous hour's tube-feeding volume. If the gastric residual is high, the feeding is stopped and gastric residual is rechecked again every 30 minutes until it is within a safe volume for resuming the feeding. Adding more formula or water would exacerbate the problem.