# Situation: A 66-year-old man had a partial glossectomy and neck dissection for oral cancer. He receives continuous formula through a small-bore nasogastric (NG) tube whose position was confirmed by radiograph (X-ray) after insertion; the tube's mark reads 60 cm at the nostril. His unit still checks gastric residual volume (GRV) every 4 hours; the protocol holds feeding only for a GRV of 500 mL or more, or for vomiting or abdominal distension. At 12:00 the GRV is 320 mL. His abdomen is soft and not distended, he has no nausea or vomiting, and the tube mark still reads 60 cm. What should the nurse do?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630472  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 66-year-old man had a partial glossectomy and neck dissection for oral cancer. He receives continuous formula through a small-bore nasogastric (NG) tube whose position was confirmed by radiograph (X-ray) after insertion; the tube's mark reads 60 cm at the nostril.

His unit still checks gastric residual volume (GRV) every 4 hours; the protocol holds feeding only for a GRV of 500 mL or more, or for vomiting or abdominal distension. At 12:00 the GRV is 320 mL. His abdomen is soft and not distended, he has no nausea or vomiting, and the tube mark still reads 60 cm. What should the nurse do?

## 보기

1. Hold the feeding and recheck in 1 hour
2. Continue feeding at the current rate **✔ 정답**
3. Reduce the feeding rate by one half
4. Stop the feeding and call the physician

**정답: 2**

## 해설

Gastric residual volume does not reliably predict aspiration, and routine checks are no longer recommended. Where a unit still measures it, feeding is not held for a volume below 500 mL unless there are other signs of intolerance such as vomiting or distension. Older cut-offs of 100 to 250 mL are outdated and cause unnecessary interruptions.

## 심화 해설

Current thinking on gastric residual volume
Gastric residual volume (GRV) is the amount of fluid aspirated from the stomach through a feeding tube. It was long used to judge whether a client was tolerating tube feeding. GRV does not reliably predict aspiration, and routine checks are no longer recommended; where a unit still measures it, feeding is not held for a volume below 500 mL unless there are other signs of intolerance. This client's GRV is 320 mL, his abdomen is soft and not distended, he has no nausea or vomiting, and the tube mark is unchanged at 60 cm. The nurse continues the feeding at the current rate.

Applying the unit protocol
The unit's protocol holds feeding only for a GRV of 500 mL or more, or for vomiting or abdominal distension. None of these criteria is met. The unchanged external mark shows the tube has not moved since its position was confirmed by X-ray. All findings therefore support safe continuation.

| Finding | This client | Hold criterion met? |
| --- | --- | --- |
| GRV | 320 mL | No (threshold 500 mL) |
| Vomiting | None | No |
| Abdominal distension | Soft, not distended | No |
| Tube mark | 60 cm, unchanged | No sign of displacement |

Why holding or reducing is harmful
Older cut-offs of 100 to 250 mL are outdated. Holding feedings for moderate residuals interrupts nutrition without reducing aspiration, and clients who have had major head and neck surgery need adequate protein and calories for wound healing. Holding and rechecking in 1 hour, halving the rate, and stopping the feeding all reduce delivered nutrition without a clinical reason. Stopping is reserved for vomiting, distension, or signs of aspiration.

Watch out! A residual of 320 mL can look large if you remember older textbooks. Use the threshold given in the stem and look at the whole client: abdomen, nausea, vomiting, and tube position.

Reducing aspiration risk
Other measures do more to prevent aspiration than GRV checks: keeping the head of the bed raised at 30–45°, checking tube position by the external mark at regular intervals, and watching for coughing, vomiting, or breathing changes. The aspirated residual is usually returned to the client to avoid losing fluid and electrolytes, according to policy. Key point! Do not hold tube feeding for a residual below 500 mL when there are no signs of intolerance; assess the whole client.

## 임상 시나리오

Gastric Residual VolumeContinuous NG feeding
GRV 320 mL, soft abdomen, no nausea or vomiting, tube mark unchanged at 60 cm: continue feeding at the current rate.

GRV does not reliably predict aspiration; the protocol holds feeding only for 500 mL or more, vomiting, or distension.

Aspiration prevention relies on head of bed 30–45°, checking the tube mark, and watching for coughing or breathing changes.

CautionOlder cut-offs of 100 to 250 mL are outdated and cause unnecessary interruptions in nutrition.

## 핵심 개념

- **Gastric residual volume** — The volume of fluid aspirated from the stomach through a feeding tube.
- **Enteral nutrition** — Delivery of nutrients into the gastrointestinal tract, usually through a feeding tube.
- **Small-bore nasogastric tube** — A narrow, flexible tube passed through the nose into the stomach for feeding.
- **Aspiration** — Entry of food, fluid, or secretions into the airway and lungs.

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