Fundamentals of Nursing Q 269
The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a comatose client. Which of the following actions is an inappropriate practice by the nurse?
A. If bowel sounds are absent, hold the feeding and notify the physician.
B. Assess tube placement by aspirating gastric content and check the PH level.
C. Warm the feeding to room temperature to prevent the occurrence of diarrhea and cramps.
D. Elevate the head of the bed to 45 degrees and maintain for 30 minutes after installation of feeding.
Correct Answer: D. Elevate the head of the bed to 45 degrees and maintain for 30 minutes after instillation of feeding.
If the client is comatose, place in a high-Fowler’s which is at a 90-degree level. Position client upright or in full Fowler’s position if possible. Place a clean towel over the client’s chest. Full Fowler’s position assists the client to swallow, for optimal neck-stomach alignment and promotes peristalsis.
Option A: Inject 30 mL of air into the stomach and listen with the stethoscope for the “whoosh” of air into the stomach. The small diameter of some NG tubes may make it difficult to hear air entering the stomach. It is very important to ensure that the NG tube is in its correct place within the stomach because, if by accident the NG is within the trachea, serious complications in relation to the lungs would appear.
Option B: Stomach aspirate will appear cloudy, green, tan, off-white, bloody, or brown. It is not always visually possible to distinguish between the stomach and respiratory aspirates. Measuring the pH of stomach aspirate is considered more accurate than visual inspection. Stomach aspirate generally has a pH range of 0 to 4, commonly less than 4.
Option C: For powdered formula, mix according to the instructions on the package. Prepare just enough for the next 24 hours and refrigerate unused formula. Allow the formula to reach room temperature before using. Formula loses its nutritional value and can be contaminated if kept for more than 24 hours. Cold formulas can cause abdominal discomfort.