A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?

A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?

• A. Keep formula cold until instillation
• B. Withhold the feeding if the residual volume is 150 mL
• C. CleansE top of the can of formula with an alcohol wipe
• D. Flush tube with 30 mL of sterile water before the feeding

Answer: (C)

The key idea here is keeping the formula free from contamination before it goes into the NG tube. Wiping the top of the formula can with an alcohol wipe before opening it is a standard aseptic step to prevent introducing bacteria into the mixture. Contaminated formula can lead to infection or sepsis in a patient with an enteral tube, so this precaution is prioritized. Keeping formula cold until instillation isn’t typically advised because formula is often refrigerated for storage but brought to a suitable temperature for administration to improve tolerance. Allowing it to remain cold through the instillation can cause GI discomfort and does not align with typical preparation steps. Withholding feeding based on a residual volume of 150 mL depends on facility policy and specific thresholds; many protocols use higher cutoffs or a broader assessment of tolerance. Relying on a single residual value isn’t a universal rule and isn’t the strongest preventive action by itself. Flushing the tube before feeding is important for patency, but stating that the flush must be sterile water isn’t universally required; many facilities use plain water for flushing according to policy. The core safeguard is maintaining patency and following guidelines for water volume, not the insistence on sterile water. So cleaning the can top with alcohol wipe before opening best minimizes contamination risk and is the action that most directly protects the safety of the feeding.

The key idea here is keeping the formula free from contamination before it goes into the NG tube. Wiping the top of the formula can with an alcohol wipe before opening it is a standard aseptic step to prevent introducing bacteria into the mixture. Contaminated formula can lead to infection or sepsis in a patient with an enteral tube, so this precaution is prioritized.

Keeping formula cold until instillation isn’t typically advised because formula is often refrigerated for storage but brought to a suitable temperature for administration to improve tolerance. Allowing it to remain cold through the instillation can cause GI discomfort and does not align with typical preparation steps.

Withholding feeding based on a residual volume of 150 mL depends on facility policy and specific thresholds; many protocols use higher cutoffs or a broader assessment of tolerance. Relying on a single residual value isn’t a universal rule and isn’t the strongest preventive action by itself.

Flushing the tube before feeding is important for patency, but stating that the flush must be sterile water isn’t universally required; many facilities use plain water for flushing according to policy. The core safeguard is maintaining patency and following guidelines for water volume, not the insistence on sterile water.

So cleaning the can top with alcohol wipe before opening best minimizes contamination risk and is the action that most directly protects the safety of the feeding.