A nurse is caring for an infant who is not tolerating enteral feeding through a nasogastric tube. The provider inserts a nasojejunal feeding tube and prescribes bolus enteral feedings. Which of the following actions should the nurse take first?
Educate the infant's caregiver about the feeding.
Flush the feeding tube before the feeding.
Clarify the feeding prescription with the provider.
Place a label on the feeding bag and tubing.
The Correct Answer is C
A. Educate the infant's caregiver about the feeding: While important, education should occur after ensuring the prescription is correct.
B. Flush the feeding tube before the feeding: This ensures patency but should only be done after verifying the prescription.
C. Clarify the feeding prescription with the provider. Bolus feedings are typically contraindicated with nasojejunal tubes because the jejunum cannot handle large volumes at once. Continuous feedings are usually prescribed. The prescription should be clarified before proceeding.
D. Place a label on the feeding bag and tubing: Labeling is necessary for safety but is not the priority when the prescription may be inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Your child needs mechanical ventilation." Mechanical ventilation is unnecessary if the child is awake and alert.
B. "We need to observe your child for cerebral swelling." Submersion injuries can lead to complications like cerebral edema or acute respiratory distress syndrome (ARDS), even if the child initially appears stable. Observation is essential to identify and address delayed complications.
C. "Your child needs to have an electroencephalogram." Electroencephalograms (EEGs) are not routine unless seizures or brain activity concerns are present.
D. "We need to perform an echocardiogram on your child." Echocardiograms are not standard for submersion injuries unless cardiac dysfunction is suspected.
Correct Answer is D
Explanation
A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale.": Incorrect because the child should exhale forcefully and quickly into the device, not inhale or hold their breath.
B. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor.": Incorrect because a green zone reading indicates controlled asthma, and no immediate action is required.
C. "I will slowly exhale through the mouthpiece over a 10-second interval.": Incorrect because the exhalation should be rapid and forceful to measure peak flow effectively.
D. "I will record the highest reading of the three attempts." Recording the highest reading ensures accurate monitoring of airway status and helps the child track their progress over time.
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