NORCERT 8 Mains-2025
Medical Surgical Nursing
Medium
A patient admitted in the ICU is receiving feeding through a Ryles tube. The nursing officer is about to give the next feed, which is scheduled for every 3 hours. Upon aspirating the stomach content, 600 ml is received in the syringe. What should be the next intervention by the nursing officer?
Appeared in: NORCERT 8 Mains-2025
Explanation
- A gastric residual volume (GRV) of 600 ml is significantly above the recommended threshold, which is often cited as 500 ml, for withholding enteral feeds.
- This high volume indicates delayed gastric emptying, which places the patient at a high risk for regurgitation and life-threatening aspiration pneumonia.
- The standard and safest nursing practice is to withhold the scheduled feeding, return the aspirate according to facility policy, and reassess the patient's tolerance and GRV after a specified period (e.g., 1-2 hours).
- This allows time for the stomach to empty and prevents further complications.
Why Other Options Were Wrong
- Option A: Feeding the patient would add more volume to an already overdistended stomach, dangerously increasing the pressure and the risk of vomiting and aspiration.
- Option C: Placing the patient in a supine (flat) position is contraindicated as it eliminates the protective effect of gravity and significantly increases the risk of gastroesophageal reflux and aspiration, especially with a high GRV.
- Option D: A single high GRV reading is a sign of feeding intolerance, not an absolute indication for tube removal. The tube may be needed for gastric decompression or for subsequent feeding attempts once the issue is resolved.
Related Visual
Clinical Relevance
- Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Management of Gastric Residual Volume (GRV) in Enteral Nutrition in acute care settings.
- Preventing aspiration pneumonia is a critical patient safety goal for any patient receiving enteral nutrition. It is a common, but preventable, complication.
- Nurses play a vital role in assessing feeding tolerance through regular monitoring of GRV, abdominal assessment (distention, bowel sounds), and observing for patient symptoms like nausea or cramping.
- Accurate assessment and timely intervention for high GRV can prevent serious adverse events and improve patient outcomes.
How to Approach the Question
- First, identify the key clinical finding in the scenario: a gastric residual volume (GRV) of 600 ml.
- Next, interpret this value. Recognize that 600 ml is a very high GRV, far exceeding the typical safety threshold of 500 ml, indicating a problem with gastric emptying.
- Consider the primary risk associated with this finding, which is aspiration pneumonia from regurgitation of stomach contents.
- Evaluate each option based on patient safety principles. The safest action is to avoid adding more volume to the already full stomach.
- Eliminate options that are clearly dangerous (feeding the patient, placing them supine) or an inappropriate overreaction (immediately removing the tube).
- Select the option that involves pausing the intervention and reassessing the patient's condition, which is the standard, safe protocol for managing feeding intolerance.
Concept Tested & Keywords
- Concept Tested: Management of Gastric Residual Volume (GRV) in Enteral Nutrition
- Stem keywords: ICU, Ryles tube, feeding, aspirating, 600 ml
- Lead-in keywords: next intervention
- Clinical cues: Aspirated volume of 600 ml is a critical value indicating severe feeding intolerance.
Question ID
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