NCLEX-RNBasic Care and ComfortHard
A client receiving continuous enteral tube feeding at 60 mL/hr through a gastrostomy tube has a gastric residual volume (GRV) of 520 mL when checked per facility protocol. What should the nurse do first?
- AContinue the feeding as ordered since GRV is not clinically significant
- BIncrease the feeding rate to help empty the stomach faster
- CStop the feeding, hold for 1 hour, and reassess the GRV before resuming
- DDiscontinue the feeding permanently and notify the provider immediately
Show answer & explanationAnswer & explanation
Correct answer: C. Stop the feeding, hold for 1 hour, and reassess the GRV before resuming
A GRV greater than 500 mL indicates delayed gastric emptying and risk for aspiration; facility protocols typically direct the nurse to hold the feeding temporarily and reassess before resuming, rather than immediately discontinuing or increasing the rate.
Why the other options are wrong
- A. A GRV of 520 mL exceeds the typical 500 mL threshold and cannot be ignored.
- B. Increasing the rate would worsen distension and aspiration risk.
- D. Permanent discontinuation without reassessment is an overreaction not supported by protocol.
Gastric Residual Volume (GRV) Monitoring
Assessment of the amount of formula/fluid remaining in the stomach during enteral feeding, used to evaluate gastric emptying and aspiration risk.
- GRV greater than 500 mL is generally considered high and warrants holding the feeding
- Reassess GRV per protocol (often after 1 hour) before resuming
- Elevated GRV may indicate delayed gastric emptying or intolerance
Memory trick: Over 500? Hold and check again before you feed.