The nurse is checking the gastric aspirate for the patient receiving tube feedings.She notes the 200 mL of pale yellow and cloudy fluid with a pH of 7.3.Which action should she take?

A) Stop the feeding immediately; then notify the prescribing provider.
B) Hold the tube feeding for 2 hours; continue if residual is less than 200 mL.
C) Flush tube with 30 mL of sterile water; resume tube feeding at prescribed rate.
D) Administer a promotility agent as prescribed; resume feeding in 1 hour.

Question

naman Jindal · Accepted Answer

Final Answer : A, Explanation :   Normal gastric fluid should be clear,green,and acidic (pH 5.0).If the gastric aspirate is pale yellow and cloudy with a pH of 7.3 (alkaline),the nurse must stop the tube feeding immediately and notify the prescriber of the feedings.This finding might indicate the feeding tube has migrated to the lungs,which could lead to aspiration pneumonia and become a medical emergency.Holding the feeding for 2 hours and continuing after that could lead to aspiration pneumonia because the quality of the fluid indicates the placement of the tube is in the lungs.Flushing the tube and resuming feedings when the feeding tube is in the lungs could lead to a medical emergency.A promotility agent (e.g.,metoclopramide)would be given if the patient has gastric residual volume (GRV)of 250 mL or more for two consecutive checks.However,if the GVR is more than 500 mL,the nurse would stop the feeding and reassess the patient.

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