Hinkle 39

Question 1

The nurse determines that a client who has undergone skin, tissue, and muscle
grafting following a modified radical neck dissection requires suctioning. What is the
nurse’s priority when suctioning this client?
A. Avoid applying suction on or near the suture line.
B. Position client on the non-operative side with the head of the bed down.
C. Assess the client’s ability to perform self-suctioning.
D. Evaluate the client’s ability to swallow saliva and clear fluids.

Answer 1

ANS: A
Rationale: The nurse should avoid positioning the suction catheter on or near the graft
suture lines. Application of suction in these areas could damage the graft. Self-sectioning
may be unsafe because the client may damage the suture line. Following a modified
radical neck dissection with graft, the client is usually positioned with the head of the bed
elevated to promote drainage and reduce edema. Assessing the viability of the graft is
important but is not part of the suctioning procedure and may delay initiating suctioning.
Maintenance of a patent airway is a nursing priority. Similarly, the client’s ability to
swallow is an important assessment for the nurse to make; however, it is not directly
linked to the client’s need for suctioning.

Question 2

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett
esophagus with minor cell changes. What principle should be integrated into the client’s
subsequent care?
A. The client will be monitored closely to detect malignant changes.
B. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause
hepatic damage.
C. Small amounts of blood are likely to be present in the stools and are not cause
for concern.
D. Antacids may be discontinued when symptoms of heartburn subside.

Answer 2

ANS: A
Rationale: In the client with Barrett esophagus, the cells lining the lower esophagus have
undergone change and are no longer squamous cells. The altered cells are considered
precancerous and are a precursor to esophageal cancer, necessitating close monitoring.
H2 receptor antagonists are commonly prescribed for clients with GERD; however,
monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding
or that are tarry are not expected and should be reported immediately. When antacids
are prescribed for clients with GERD, they should be taken as prescribed whether or not
the client is symptomatic.

Question 3

A medical nurse who is caring for a client being discharged home after a radical neck
dissection has collaborated with the home health nurse to develop a plan of care for this
client. What is a priority psychosocial outcome for this client?
A. Indicates acceptance of altered appearance and demonstrates positive
self-image
B. Freely expresses needs and concerns related to postoperative pain management
C. Compensates effectively for alteration in ability to communicate related to
dysarthria
D. Demonstrates effective stress management techniques to promote muscle
relaxation

Answer 3

ANS: A
Rationale: Since radical neck dissection involves removal of the sternocleidomastoid
muscle, spinal accessory muscles, and cervical lymph nodes on one side of the neck, the
client’s appearance is visibly altered. The face generally appears asymmetric, with a
visible neck depression; shoulder drop also occurs frequently. These changes have the
potential to negatively affect self-concept and body image. Facilitating adaptation to
these changes is a crucial component of nursing intervention. Clients who have had head
and neck surgery generally report less pain as compared with other postoperative
clients; however, the nurse must assess each individual client’s level of pain and
response to analgesics. Clients may experience transient hoarseness following a radical
neck dissection; however, their ability to communicate is not permanently altered. Stress
management is beneficial but would not be considered the priority in this clinical
situation.

Question 4

A client has been diagnosed with an esophageal diverticulum after undergoing
diagnostic imaging. When taking the health history, the nurse should expect the client to
describe what sign or symptom?
A. Burning pain on swallowing
B. Regurgitation of undigested food
C. Symptoms mimicking a myocardial infarction
D. Chronic parotid abscesses

Answer 4

ANS: B
Rationale: An esophageal diverticulum is an outpouching of mucosa and submucosa that
protrudes through the esophageal musculature. Food becomes trapped in the pouch and
is frequently regurgitated when the client assumes a recumbent position. The client may
experience difficulty swallowing; however, burning pain is not a typical finding.
Symptoms mimicking a heart attack are characteristic of GERD. Chronic parotid
abscesses are not associated with a diagnosis of esophageal diverticulum.

Question 5

A nurse is caring for a client who is acutely ill and has included vigilant oral care in the
client’s plan of care. What factor increases this client’s risk for dental caries?
A. Hormonal changes brought on by the stress response cause an acidic oral
environment
B. Systemic infections frequently migrate to the teeth
C. Hydration that is received intravenously lacks fluoride
D. Inadequate nutrition and decreased saliva production can cause cavities

Answer 5

ANS: D
Rationale: Many ill clients do not eat adequate amounts of food and therefore produce
less saliva, which in turn reduces the natural cleaning of the teeth. Stress response is not
a factor, infections generally do not attack the enamel of the teeth, and the fluoride level
of the client is not significant in the development of dental caries in the ill client.

Question 6

A nurse who provides care in an ambulatory clinic integrates basic cancer screening
into admission assessments. What client most likely faces the highest immediate risk of
oral cancer?
A. A 65-year-old man with alcoholism who smokes
B. A 45-year-old woman who has type 1 diabetes and who wears dentures
C. A 32-year-old man who is obese and uses smokeless tobacco
D. A 57-year-old man with GERD and dental caries

Answer 6

ANS: A
Rationale: Oral cancers are often associated with the use of alcohol and tobacco, which
when used together have a synergistic carcinogenic effect. Most cases of oral cancers
occur in people over the age of 60 and a disproportionate number of cases occur in men.
Diabetes, dentures, dental caries, and GERD are not risk factors for oral cancer.

Question 7

A nurse is caring for a client who has undergone neck resection with a radial forearm
free flap. The nurse’s most recent assessment of the graft reveals that it has a bluish
color and that mottling is visible. What is the nurse’s most appropriate action?
A. Document the findings as being consistent with a viable graft.
B. Promptly report these indications of venous congestion.
C. Closely monitor the client and reassess in 30 minutes.
D. Reposition the client to promote peripheral circulation.

Answer 7

ANS: B
Rationale: A graft that is blue with mottling may indicate venous congestion. This finding
constitutes a risk for tissue ischemia and necrosis; prompt referral is necessary.

Question 8

A nurse is assessing a client who has just been admitted to the postsurgical unit
following surgical resection for the treatment of oropharyngeal cancer. What assessment
should the nurse prioritize?
A. Assess ability to clear oral secretions.
B. Assess for signs of infection.
C. Assess for a patent airway.
D. Assess for ability to communicate.

Answer 8

ANS: C
Rationale: Postoperatively, the nurse assesses for a patent airway. The client’s ability to
manage secretions has a direct bearing on airway patency. However, airway patency is
the overarching goal. This immediate physiologic need is prioritized over communication,
though this is an important consideration. Infection is not normally a threat in the
immediate postoperative period.

Question 9

A client who has had a radical neck dissection is being prepared for discharge. The
discharge plan includes referral to an outpatient rehabilitation center for physical
therapy. What should the goals of physical therapy for this client include?
A. Muscle training to relieve dysphagia
B. Relieving nerve paralysis in the cervical plexus
C. Promoting maximum shoulder function
D. Alleviating achalasia by decreasing esophageal peristalsis

Answer 9

ANS: C
Rationale: Shoulder drop occurs as a result of radical neck dissection. Shoulder function
can be improved by rehabilitation exercises. Rehabilitation would not be initiated until
theclient’s neck incision and graft, if present, were sufficiently healed. Nerve paralysis in the cervical plexus and other variables affecting swallowing would be managed by a speech
therapist rather than a physical therapist.

Question 10

A nurse is addressing the prevention of esophageal cancer in response to a question
posed by a participant in a health promotion workshop. What action should the nurse
recommend as having the greatest potential to prevent esophageal cancer?
A. Promotion of a nutrient-dense, low-fat diet
B. Annual screening endoscopy for clients over 50 with a family history of
esophageal cancer
C. Early diagnosis and treatment of gastroesophageal reflux disease
D. Adequate fluid intake and avoidance of spicy foods

Answer 10

ANS: C
Rationale: There are numerous risk factors for esophageal cancer but chronic esophageal
irritation or GERD is among the most significant. This is a more significant risk factor than
dietary habits. Screening endoscopies are not recommended solely on the basis of family
history.

Question 11

An emergency department nurse is admitting a 3-year-old brought in after
swallowing a piece from a wooden puzzle. The nurse should anticipate the administration
of what medication in order to relax the esophagus to facilitate removal of the foreign
body?
A. Haloperidol
B. Prostigmine
C. Epinephrine
D. Glucagon

Answer 11

ANS: D
Rationale: Glucagon is given prior to removal of a foreign body because it relaxes the
smooth muscle of the esophagus, facilitating insertion of the endoscope. Haloperidol is an
antipsychotic drug and is not indicated. Prostigmine is prescribed for clients with
myasthenia gravis. It increases muscular contraction, an effect opposite that which is
desired to facilitate removal of the foreign body. Epinephrine is indicated in asthma
attack and bronchospasm.

Question 12

A nurse in an oral surgery practice is working with a client scheduled for removal of
an abscessed tooth. When providing discharge education, the nurse should recommend
what action?
A. Rinse the mouth with alcohol before bedtime for the next 7 days.
B. Use warm saline to rinse the mouth as needed.
C. Brush around the area with a firm toothbrush to prevent infection.
D. Use a toothpick to dislodge any debris that gets lodged in the socket.

Answer 12

ANS: B
Rationale: The client should be assessed for bleeding after the tooth is extracted. The
mouth can be rinsed with warm saline to keep the area clean. A firm toothbrush or
toothpick could injure the tissues around the extracted area. Alcohol would injure tissues
that are healing.

Question 13

A client has been diagnosed with a malignancy of the oral cavity and is undergoing
oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from
head and neck cancers is often poor because of what characteristic of these
malignancies?
A. Radiation therapy often results in secondary brain tumors.
B. Surgical complications are exceedingly common.
C. Diagnosis rarely occurs until the cancer is end stage.
D. Metastases are common and respond poorly to treatment.

Answer 13

ANS: D
Rationale: Deaths from malignancies of the head and neck are primarily attributable to
local-regional metastasis to the cervical lymph nodes in the neck. This often occurs by
way of the lymphatics before the primary lesion has been treated. This local-regional
metastasis is not amenable to surgical resection and responds poorly to chemotherapy
and radiation therapy. This high mortality rate is not related to surgical complications,
late diagnosis, or the development of brain tumors.

Question 14

A client has undergone surgery for oral cancer and has just been extubated in
postanesthetic recovery. What nursing action best promotes comfort and facilitates
spontaneous breathing for this client?
A. Placing the client in a left lateral position
B. Administering opioids as prescribed
C. Placing the client in Fowler position
D. Teaching the client to use the client-controlled analgesia (PCA) system

Answer 14

ANS: C
Rationale: After the endotracheal tube or airway has been removed and the effects of the
anesthesia have worn off, the client may be placed in Fowler position to facilitate
breathing and promote comfort. Lateral positioning does not facilitate oxygenation or
comfort. Medications do not facilitate spontaneous breathing.

Question 15

A client has undergone rigid fixation for the correction of a mandibular fracture
suffered in a fight. What area of care should the nurse prioritize when planning this
client’s discharge education?
A. Resumption of activities of daily living
B. Pain control
C. Promotion of adequate nutrition
D. Strategies for promoting communication

Answer 15

ANS: C
Rationale: The client who has had rigid fixation should be instructed not to chew food in
the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary
counseling
should be obtained to ensure optimal caloric and protein intake. The nature of this
surgery threatens the client’s nutritional status; this physiologic need would likely
supersede the resumption of ADLs. Pain should be under control prior to discharge and
communication is not precluded by this surgery.

Question 16

A The client is experiencing painful oral lesions following radiation for oropharyngeal
cancer. Which instruction should the nurse give this client?
A. Spicy foods stimulate salivation and are soothing.
B. Eat food while it is hot to enhance flavor.
C. Avoid brushing teeth while lesions are present.
D. Eat soft or liquid foods.

Answer 16

ANS: D
Rationale: Since oral lesions can be painful, a soft or liquid diet may be preferred and
easier to ingest. Other strategies to reduce pain and discomfort include avoiding spicy
and hot foods. The client should continue with mouth care and brushing teeth with a soft
toothbrush to keep the oral cavity clean.

Question 17

A nurse is caring for a client who is postoperative day 1 following neck dissection
surgery. The nurse is performing an assessment of the client and notes the presence of
high-pitched adventitious sounds over the client’s trachea on auscultation. The client’s
oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per
minute. What is the nurse’s most appropriate action?
A. Encourage the client to perform deep breathing and coughing exercises hourly.
B. Reposition the client into a prone or semi-Fowler position and apply
supplementary oxygen by nasal cannula.
C. Activate the emergency response system.
D. Report this finding promptly to the health care provider and remain with the
client.

Answer 17

ANS: D
Rationale: In the immediate postoperative period, the nurse assesses for stridor (coarse,
high-pitched sound on inspiration) by listening frequently over the trachea with a
stethoscope. This finding must be reported immediately because it indicates obstruction
of the airway. The client’s current status does not warrant activation of the emergency
response system, and encouraging deep breathing and repositioning the client are
inadequate responses.

Question 18

A nurse is providing care for a client whose neck dissection surgery involved the use
of a graft. When assessing the graft, the nurse should prioritize data related to what
nursing diagnosis?
A. Risk for disuse syndrome
B. Unilateral neglect
C. Risk for trauma
D. Ineffective tissue perfusion

Answer 18

ANS: D
Rationale: Grafted skin is highly vulnerable to inadequate perfusion and subsequent
ischemia and necrosis. This is a priority over chronic pain, which is unlikely to be a
long-term challenge. Neglect and disuse are not risks related to the graft site.

Question 19

A client who underwent surgery for esophageal cancer is admitted to the critical care
unit following postanesthetic recovery. What should the nurse include in the client’s
immediate postoperative plan of care?
A. Teaching the client to self-suction
B. Performing chest physiotherapy to promote oxygenation
C. Positioning the client to prevent gastric reflux
D. Providing a regular diet as tolerated

Answer 19

ANS: C
Rationale: After recovering from the effects of anesthesia, the client is placed in a low
Fowler position, and later in a Fowler position, to help prevent reflux of gastric secretions.
The client is observed carefully for regurgitation and dyspnea because a common
postoperative complication is aspiration pneumonia. In this period of recovery,
self-suctioning is also not likely realistic or safe. Chest physiotherapy is contraindicated
because of the risk of aspiration. Nutrition is prioritized, but a regular diet is
contraindicated in the immediate recovery from esophageal surgery.

Question 19

A client’s neck dissection surgery resulted in damage to the client’s superior laryngeal
nerve. What area of assessment should the nurse consequently prioritize?
A. The client’s swallowing ability
B. The client’s ability to speak
C. The client’s management of secretions
D. The client’s airway patency

Answer 19

ANS: A
Rationale: If the superior laryngeal nerve is damaged, the client may have difficulty
swallowing liquids and food because of the partial lack of sensation of the glottis. Damage
to this particular nerve does not inhibit speech and only indirectly affects management of
secretions and airway patency.

Question 20

. A client with GERD has undergone diagnostic testing and it has been determined that
increasing the pace of gastric emptying may help alleviate symptoms. The nurse should
anticipate that the client may be prescribed what drug?
A. Metoclopramide
B. Omeprazole
C. Lansoprazole
D. Calcium carbonate

Answer 20

ANS: A
Rationale: Metoclopramide (Reglan) is useful in promoting gastric motility. Omeprazole
and lansoprazole are proton pump inhibitors that reduce gastric acid secretion. Calcium
carbonate does not affect gastric emptying.

Question 20

A nurse is caring for a client who has had surgery for oral cancer. When addressing
the client’s long-term needs, the nurse should prioritize interventions and referrals with
what goal?
A. Enhancement of verbal communication
B. Enhancement of immune function
C. Maintenance of adequate social support
D. Maintenance of fluid balance

Answer 20

ANS: A
Rationale: Verbal communication may be impaired by radical surgery for oral cancer.
Addressing this impairment often requires a long-term commitment. Immune function,
social support, and fluid balance are all necessary, but communication is a priority issue
for clients recovering from this type of surgery.

Question 20

A client returns to the unit after a neck dissection. The surgeon placed a Jackson-Pratt
drain in the wound. When assessing the wound drainage over the first 24 postoperative
hours the nurse would notify the health care provider immediately for what finding?
A. Presence of small blood clots in the drainage
B. 60 mL of milky or cloudy drainage
C. Spots of drainage on the dressings surrounding the drain
D. 120 mL of serosanguinous drainage

Answer 20

ANS: B
Rationale: Between 80 and 120 mL of serosanguineous secretions may drain over the
first 24 hours. Milky drainage is indicative of a chyle fistula, which requires prompt
treatment.

Question 20

A client seeking care because of recurrent heartburn and regurgitation is
subsequently diagnosed with a hiatal hernia. Which of the following should the nurse
include in health education?
A. “Drinking beverages after your meal, rather than with your meal, may bring
some relief.”
B. “It’s best to avoid dry foods, such as rice and chicken, because they’re harder to
swallow.”
C. “Many clients obtain relief by taking over-the-counter antacids 30 minutes
before eating.”
D. “Instead of eating three meals a day, try eating smaller amounts more often.”

Answer 20

ANS: D
Rationale: Management for a hiatal hernia includes frequent, small feedings that can
pass easily through the esophagus. Avoiding beverages and particular foods or taking
OTC antacids are not noted to be beneficial.

Question 21

A nurse is caring for a client who has just had a rigid fixation of a mandibular fracture.
When planning the discharge teaching for this client, what would the nurse be sure to
include?
A. Increasing calcium intake to promote bone healing
B. Avoiding chewing food for the specified number of weeks after surgery
C. Techniques for managing parenteral nutrition in the home setting
D. Techniques for managing a gastrostomy

Answer 21

ANS: B
Rationale: The client who has had rigid fixation should be instructed not to chew food in
the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling
should be obtained to ensure optimal caloric and protein intake. Increased calcium intake
will not have an appreciable effect on healing. Enteral and parenteral nutrition are rarely
necessary.

Question 21

A nurse is caring for a client who is postoperative from a neck dissection. What would
be the most appropriate nursing action to enhance the client’s appetite?
A. Encourage the family to bring in the client’s favorite foods.
B. Limit visitors at mealtimes so that the client is not distracted.
C. Avoid offering food unless the client initiates.
D. Provide thorough oral care immediately after the client eats.

Answer 21

ANS: A
Rationale: Family involvement and home-cooked favorite foods may help the client to
eat. Having visitors at mealtimes may make eating more pleasant and increase the
client’s appetite. The nurse should not place the complete onus for initiating meals on the
client. Oral care after meals is necessary, but does not influence appetite.

Question 22

The nurse is preparing to check for tube placement in the client’s stomach as well as
measure the residual volume. What are these nursing actions attempting to prevent?
A. Gastric ulcers
B. Aspiration
C. Abdominal distention
D. Diarrhea

Answer 22

ANS: B
Rationale: Protecting the client from aspirating is essential because aspiration can cause
pneumonia, a potentially life-threatening disorder. Gastric ulcers are not a common
complication of tube feeding in clients with ET tubes. Abdominal distention and diarrhea
can both be associated with tube feeding, but prevention of these problems is not the
primary rationale for confirming placement.

Question 23

The management of the client’s gastrostomy is an assessment priority for the home
care nurse. What statement would indicate that the client is managing the tube correctly?
A. “I clean my stoma twice a day with alcohol.”
B. “The only time I flush my tube is when I’m putting in medications.”
C. “I flush my tube with water before and after each of my medications.”
D. “I try to stay still most of the time to avoid dislodging my tube.

Answer 23

ANS: C
Rationale: Frequent flushing is needed to prevent occlusion, and should not just be
limited to times of medication administration. Alcohol will irritate skin surrounding the
insertion site and activity should be maintained as much as possible.

Question 24

A client’s NG tube has become clogged after the nurse instilled a medication that was
insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe,
with no success. What should the nurse do next?
A. Withdraw the NG tube 2 inches (5 cm) and reattempt aspiration.
B. Attach a syringe filled with warm water and attempt an in-and-out motion of
instilling and aspirating.
C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with
the fingers.
D. Remove the NG tube promptly and obtain an order for reinsertion from the
primary care provider.

Answer 24

ANS: B
Rationale: Warm water irrigation is one of the methods that can be used to unclog a
feeding tube. Removal is not warranted at this early stage and a flicking motion is
unlikely to have an effect. The tube should not be withdrawn, even a few centimeters.

Question 25

The nurse is administering medications to a client through a feeding tube. Which
action should the nurse take?
A. Flush the tube with 5 mL of water before administering medication.
B. Turn the tube feeding off for 1 hour before administering the medication.
C. Administer each medication separately.
D. Flush with 50 mL of water between each medication.

Answer 25

ANS: C
Rationale: When administering several medications through a feeding tube, each
medication should be administered separately with 15 mL of water administered between
each medication. Prior to administering medication, the tube feed should be paused
(there is no need to wait one hour) and flushed with 15 mL of water.

Question 26

The nurse is administering medications to a client through a feeding tube. Which
action should the nurse take?
A. Flush the tube with 5 mL of water before administering medication.
B. Turn the tube feeding off for 1 hour before administering the medication.
C. Administer each medication separately.
D. Flush with 50 mL of water between each medication.

Answer 26

ANS: C
Rationale: When administering several medications through a feeding tube, each
medication should be administered separately with 15 mL of water administered between
each medication. Prior to administering medication, the tube feed should be paused
(there is no need to wait one hour) and flushed with 15 mL of water.

Question 27

A client who suffered a stroke had an NG tube inserted to facilitate feeding shortly
after admission. The client has since become comatose and the client’s family asks the
nurse why the health care provider is recommending the removal of the client’s NG tube
and the insertion of a gastrostomy tube. What is the nurse’s best response?
A. “It eliminates the risk for infection.”
B. “Feeds can be infused at a faster rate.”
C. “Regurgitation and aspiration are less likely.”
D. “It allows caregivers to provide personal hygiene more easily.”

Answer 27

ANS: C
Rationale: Gastrostomy is preferred over NG feedings in the client who is comatose
because the gastroesophageal sphincter remains intact, making regurgitation and
aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this
change in care is not motivated by the possibility of faster infusion or easier personal
care.

Question 28

A client has a gastrostomy tube that has been placed to drain stomach contents by
low intermittent suction. What is the nurse’s priority during this aspect of the client’s
care?
A. Measure and record drainage.
B. Monitor drainage for change in color.
C. Titrate the suction every hour.
D. Feed the client via the G tube as prescribed.

Answer 28

ANS: A
Rationale: This drainage should be measured and recorded because it is a significant
indicator of GI function. The nurse should indeed monitor the color of the output, but fluid
balance is normally the priority. Frequent titration of the suction should not be necessary
and feeding is contraindicated if the G tube is in place for drainage.

Question 29

The nurse is caring for a client who had a low-profile gastrostomy device placed.
Which instruction should the nurse give the client and family?
A. Wear the tubing outside of clothing.
B. Use tape to secure the device.
C. Bring the connection tubing if going to the hospital.
D. Change the wet-to-dry dressing daily.

Answer 29

ANS: C
Rationale: To administer a feeding with a low-profile feeding device, special tubing is
connected to the device. This client needs to be instructed to take this tubing to the
hospital and when traveling. A low-profile gastrostomy device sits flush with the skin so
it is easily concealed under clothes. The device does not require tape or other type of
securement system. This device also does not require any type of dressing, including a
wet-to-dry dressing.

Question 30

A nurse is preparing to place a client’s prescribed nasogastric tube. What anticipatory
guidance should the nurse provide to the client?
A. Insertion is likely to cause some gagging.
B. Insertion will cause some short-term pain.
C. A narrow-gauge tube will be inserted before being replaced with a larger-gauge
tube.
D. Topical anesthetics will be used to reduce discomfort during insertion.

Answer 30

ANS: A
Rationale: Insertion may cause gagging until the tube has passed beyond the throat.
Insertion is often unpleasant, but not normally painful. Anesthetic is not usually applied
and there is no initial need for a small-gauge tube

Question 31

A nurse is creating a care plan for a client receiving nasogastric tube feedings. Which
intervention should the nurse include?
A. Check the gastric residual volume every 4 hours.
B. Hold the tube feeding if the gastric residual volume is greater than 200 mL.
C. Position client flat in bed during feedings.
D. Use client assessment findings to determine tolerance of feedings.

Answer 31

ANS: D
Rationale: Client indicators of tolerance to tube feedings include abdominal distention,
client report of discomfort, vomiting, hypoactive bowel sounds, and diarrhea. Previously,
gastric residual volume (GRV) was checked as an indicator of tube feeding tolerance.
Professional organizations such as the Society of Critical Care Medicine (SCCM) and the
American Society for Parenteral and Enteral Nutrition (ASPEN) no longer advocate using
GRVs to monitor tolerance of enteral feedings. Therefore, unless policy states otherwise,
GRV should not be checked every 4 hours and the feeding should not be held for a GRV
greater than 250 mL. The head of the bed should be elevated 30 degrees while a tube
feeding is being administered to reduce the risk for aspiration.

Question 32

A nasogastric tube is being inserted in a client with the COVID virus. Which action
should the nurse take?
A. Place the client in a prone position.
B. Administer bolus feedings.
C. Place a mask over the client’s nose.
D. Wear personal protective equipment.

Answer 32

ANS: D
Rationale: Personal protective equipment must be worn when placing a nasogastric tube
in a client with COVID since it is considered an aerosol-generating procedure as tube
placement often generates a cough. The client should be placed in a supine position for
the placement of the nasogastric tube to assure proper visualization, assessment, and
advancement of the tube. If possible, a mask should be placed over the client’s mouth to
avoid transmission of the virus if the client coughs. The mask cannot be placed over the
client’s nose since the tube will be placed through the nares. The feedings should be
administered as a continuous feeding, rather than a bolus, to reduce the risk of contact
with bodily fluids and aerosolized droplets.