NCLEX-RN

Category - Physiological

A student nurse is assigned to assist the staff nurse in feeding the client with a nasogastric tube. The staff nurse asks the student nurse how to assess for delayed gastric emptying. Which of the student nurse’s responses indicates an understanding of the procedure?
  1. Ask the client if he or she feels full.
  2. Auscultate for bowel sounds.
  3. Aspirate gastric contents every four hours.
  4. Check for abdominal distention.
Explanation
Answer: C - The best method of assessing for delayed gastric emptying is to aspirate gastric contents every four hours. A full stomach may cause increased intragastric pressure, resulting in aspiration. The nurse cannot fully assess for delayed gastric emptying by asking if the client feels full, auscultating bowel sounds, or checking for abdominal distention. If there is more than 50ml of aspirated gastric contents, the next feeding should be delayed.
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