A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?

Replace the NG tube.

Lower the head of the bed to 15°.

Slow the rate of formula instillation.

Chill and readminister the formula.

Answer and Explanation

The Correct Answer is C

A. Replace the NG tube.: There is no indication that the NG tube is malfunctioning or misplaced in this case. The cramping and nausea are more likely related to the feeding itself, not the tube.

B. Lower the head of the bed to 15°.: Lowering the head of the bed would increase the risk of aspiration. The head of the bed should be elevated during enteral feeding to reduce this risk.

C. Slow the rate of formula instillation.: Abdominal cramping and nausea during enteral feeding can occur if the feeding rate is too fast. Slowing the rate allows the stomach to better tolerate the formula and can alleviate symptoms.

D. Chill and readminister the formula.: The temperature of the formula should not cause the cramping or nausea. Feeding should be administered at room temperature or as directed by protocol, and re-chilling it is unlikely to help with the symptoms.

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Correct Answer is D

Explanation

A. Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.

B. Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.

C. Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.

D. Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.

A. To stay with the client's body for 8 hr following their death B. To cremate the client's body C. To prohibit medical personnel from touching the client's body D. To bury the client's body within 24 hr of their death

Correct Answer is B

Explanation

A. To stay with the client's body for 8 hr following their death: While it is common for family members to stay with the deceased, the duration of time can vary and is not specifically aligned with Hindu customs.

B. To cremate the client's body: In Hinduism, cremation is the most common practice following death. The family is likely to request this as it aligns with religious beliefs and traditions.

C. To prohibit medical personnel from touching the client's body: In Hinduism, there is no blanket prohibition against medical personnel touching the body. However, some families may have specific requests for the handling of the body, but this is not universally expected.

D. To bury the client's body within 24 hr of their death: Hindus typically prefer cremation rather than burial. While burial is practiced in certain Hindu traditions, cremation is far more common, and the request for burial within 24 hours may not apply.

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A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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