The nurse is assessing the gastric residual volume of a client receiving enteral feedings. The nurse notes there is a residual of 250 cc. Which action by the nurse is most appropriate?
A) Reduce the amount of the next feeding by 250 cc.
B) Contact the primary care physician.
C) Document the findings.
D) Slow the next feeding to promote improved absorption.
Ans: C
Feedback:
Assessment of gastric residual volume (GRV) is a nursing function. Feedings should generally not be stopped for GRVs of more than 400 to 500 mL unless the client exhibits signs of intolerance. Clients at high risk for aspiration should be monitored based on their disease process, not solely on their GRVs.
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