A patient is receiving continuous tube feedings at 100 mL/hr. At 1400, the nurse determines that there is 175 mL of residual volume. Which action will the nurse take?
a. Continue the feedings as ordered.
b. Reduce the feeding by 50%.
c. Stop the feeding and notify the health care provider.
d. Aspirate and dispose of the residual and restart the feeding.
ANS: C
When the residual volume of a tube feeding exceeds 100 mL (or the limit set by the health care provider), the tube feeding is stopped and the residual volume is rechecked within 1 hour. When the residual volume has returned to the limits set by the health care provider, it is restarted. Because the residual amount already exceeds the recommended amount, the feeding should not continue. Infusion rate should not be changed without an order from the health care provider.
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