A nurse is caring for a client who is being tube-fed. Which of the following actions should the nurse perform when assessing a client's gastric residual volume?
A) Aspirate fluid from the tube using a 5 ml syringe.
B) Clamp the tube and wait for 15 minutes.
C) Stop the infusion of the tube-feeding formula.
D) Aspirate or flush the tube with water.
C
Feedback:
The nurse should stop the infusion of the tube-feeding formula to facilitate measurement. Next, the nurse should aspirate the fluid from the feeding tube using a 50 ml syringe, not a 5 ml syringe. Clamping the tube and waiting for 15 minutes or flushing the tube with water is done to clear an obstructed feeding tube, not to assess the gastric residual volume of a client.
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