The client receives tube feedings of 200 ml every 6 hours by intermittent gavage. The nurse prepares to administer the client's tube feeding and aspirates 200 ml of formula

Question

Choose suitable interventions that the nurse should implement after aspirating the formula and rank the interven-tions in the correct order. 1. Collaborate with the provider.
2. Administer scheduled feeding.
3. Discard aspirated tube feeding.
4. Check for abdominal distention.
5. Administer the aspirated formula.
6. Flush feeding tube with tap water.

Answer 1

3, 4, 1
3, 4, 1, and 2. The nurse discards the aspirated formula because residual volume from a tube feeding over 100 ml is excessive and increases the client's risk of complica-tions. The client's gastric aspirate is especially worrisome because the nurse aspirated the entire volume of the tube feeding, realizing that the stomach did not empty in 6 hours. The nurse should be aware of this assessment data for a client with a tube feeding because the duty the nurse owes to the client demands abdominal assess-ments at least every 4 hours. The nurse withholds the scheduled feeding and assesses the client's abdomen, including distention and bowel sounds; then the nurse presents the client data and collaborates with the provider on a plan of care.
5 and 6. The nurse avoids administering the aspirated formula or flushing the tube because any fluid potentially accumulates in the stomach, aggravates the problem, and increases the client's risk of complications.