What should a nurse do if a client has a residual of 65mL 1 hour postprandial during tube feeding?

When a client has a residual of 65mL one hour after a tube feeding, assessing for potential aspiration risk is a critical step. A residual volume indicates the amount of formula that remains in the stomach, which can reflect how well the client is tolerating the feeding. If the residual is higher than expected, it may suggest delayed gastric emptying or gastrointestinal intolerance.

Assessing for aspiration risk is important because a high residual volume increases the likelihood of reflux or incorrect placement of the feeding tube, which could lead to aspiration pneumonia if the contents are mistakenly inhaled into the lungs. Therefore, the nurse must evaluate the client for signs of aspiration, such as increased respiratory rate, coughing, or changes in oxygen saturation, and ensure that the feeding is still safe to continue.

This action prioritizes client safety and ensures that appropriate interventions can be taken if there are concerns about aspiration. In contrast to the other options, which either take immediate action based on the residual amount without proper assessment or assume that the feeding can continue without consequences, assessing for risk helps to provide a comprehensive understanding of the client’s condition and informs the best course of action moving forward.