Difficulty: Medium
Average Score: 75%
Simulated
A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?
Correct answer
C
Rationale
The presence of bowel sounds indicates that the gastrointestinal tract is functioning and can tolerate enteral feedings. Administering a feeding in the absence of bowel sounds can lead to aspiration, vomiting, and abdominal distention. Assessing swallow is irrelevant for tube feedings. Observing for fluid deficit and measuring weight are important for monitoring overall status but are not the priority immediately before initiating a feeding.