Question

96. The client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next appropriate nursing action?

A) Administer the feeding as ordered
B) Hold the next feeding
C) Flush with sterile water
D) Discard the undigested feeding

Answer 1

When a nurse aspirates more feeding than was administered to a client with ALS, the correct action is to hold the next feeding. This is to prevent complications associated with overdistention of the stomach, aspiration, or impaired digestion and absorption within the gastrointestinal tract.

Step-by-step explanation:

The question involves the administration of an enteral feeding to a client with amyotrophic lateral sclerosis (ALS). When a nurse aspirates 180 ml of feeding from a patient when only 160 ml was administered previously, it indicates that the previous feeding has not been properly digested and absorbed. The appropriate action in this case is to hold the next feeding since administering more feeding could cause harm to the patient due to the potential for overdistention of the stomach, aspiration, or other complications.

For optimal chemical digestion, it's important to ensure that the stomach and intestines are not overwhelmed by a large volume of chyme. Overdistention or rapid gastric emptying can result in complications and affect the normal function of the gastrointestinal tract. Therefore, monitoring residual gastric volume is critical in managing enteral feedings to ensure patient safety and comfort.