The nurse prepares to administer an enteral feeding to a client through a nasogastric tube. Which is the priority intervention for the nurse to complete before administering the feeding?

1. A

   Determining tube placement

2. B

   Auscultating the tube bowel sounds

3. C

   Measuring the intake and output

4. D

   Establishing the client's baseline weight

Appeared in: ISRO- 2016

Explanation

• The primary reason for determining tube placement is to prevent aspiration pneumonia, a potentially fatal complication.
• Administering feeding into a misplaced tube (e.g., in the trachea or lungs) can cause severe respiratory distress and death.
• Verifying placement is the most critical safety check a nurse must perform before every enteral feeding.
• The gold standard for initial placement confirmation is a chest X-ray.
• For subsequent checks, aspirating gastric contents and testing for a pH of 5.5 or less is the recommended practice.

Why Other Options Were Wrong

• Option B: Auscultating bowel sounds assesses GI motility, not the physical location of the tube's tip. A tube can be in the lungs while the patient has active bowel sounds.
• Option C: Measuring intake and output is a routine monitoring task for fluid balance. It does not prevent the immediate, life-threatening risk of aspiration from a misplaced tube.
• Option D: Establishing a baseline weight is a long-term evaluation parameter to assess the effectiveness of nutritional therapy over days or weeks.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Priority Nursing Interventions for Enteral Feeding in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Failure to verify tube placement before administering a feeding is a serious nursing error that can lead to significant patient harm, including death. It is considered a 'never event' in many healthcare systems.
• Nurses must be diligent in checking placement before every feeding, every medication administration, and at regular intervals during continuous feedings as per institutional policy.
• What if? The nurse aspirates stomach contents and the pH is 7.0? The nurse must withhold the feeding, as a pH this high suggests the tube may be in the small intestine or the respiratory tract. The nurse should notify the healthcare provider and anticipate an order for an X-ray to confirm placement before proceeding.

How to Approach the Question

• Identify the question type: This is a priority-setting question, indicated by the keyword 'priority'.
• Analyze the core task: The nurse is about to administer an enteral feeding.
• Apply a safety framework: Think about which action prevents the most immediate and severe harm. Use frameworks like Airway-Breathing-Circulation (ABC) or Maslow's Hierarchy.
• Evaluate the options based on safety: Misplacing a feeding into the airway is a direct threat to breathing and life. Therefore, any action that prevents this is the highest priority.
• Compare the options: Determining tube placement directly addresses the risk of aspiration (an airway/breathing issue). The other options (bowel sounds, I&O, weight) relate to GI function and long-term monitoring, which are important but not as immediately life-threatening.
• Select the option that ensures patient safety before initiating the procedure.

Concept Tested & Keywords

• Concept Tested: Priority Nursing Interventions for Enteral Feeding
• Stem keywords: enteral feeding, nasogastric tube, priority intervention
• Lead-in keywords: priority

Question ID

QohVh0ZizcgEFglQk5BUc

Copy ID

Reference Book

E6 Pharmacology Nursing Lilley 11e Part 3 p. 233-235

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 215-217

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 2 p. 90-92