A nurse is preparing to administer an enteral feeding to a preschooler who has a nasogastric tube. Which of the following actions should the nurse plan to take?

Discard residual fluid aspirated from the stomach prior to the feeding.

Administer the formula immediately after removing it from the refrigerator.

Elevate the head of the bed to a 45-degree angle.

Administer the feeding at a rate of 30 mL/min.

Answer and Explanation

The Correct Answer is C

A. Residual fluid should not be discarded unless instructed by a healthcare provider, as it provides important information about gastric emptying and tolerance to previous feedings.
B. Formula should be brought to room temperature before administration to avoid causing discomfort or gastric irritation. Cold formula can cause cramps and slow gastric motility.
C. Elevating the head of the bed to a 45-degree angle helps prevent aspiration during feeding and promotes proper digestion. This position is critical for patient safety.
D. The feeding rate should be individualized based on the child's tolerance and prescribed regimen, and 30 mL/min is typically too fast for a preschooler, increasing the risk of aspiration or intolerance.

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Correct Answer is A

Explanation

A. Bedwetting in a toilet-trained child can be a sign of emotional distress or trauma, which may indicate maltreatment and should be further investigated.
B. Stranger anxiety is a normal developmental stage for an 8-month-old infant and does not suggest maltreatment.
C. Bruises on the shins of an 18-month-old child are common due to normal toddler activity and do not necessarily indicate maltreatment.
D. Separation anxiety, including kicking and screaming when a parent leaves, is typical behavior for a 2-year-old child and does not suggest maltreatment.

A. Mix the medication in a bottle of formula. B. Mix the medication with a small amount of honey. C. Place the medication in an oral syringe. D. Place the medication in the back of the infant's throat using a dropper.

Correct Answer is C

Explanation

A. Mixing medication in a bottle of formula is not recommended as the infant may not finish the entire bottle, leading to incomplete dosage. It also changes the taste of the formula, which may cause feeding aversions.
B. Honey should not be given to infants under 1 year old due to the risk of botulism. It is not a suitable medium for mixing medication for young infants.
C. Placing the medication in an oral syringe allows for precise dosing and easy administration. It ensures that the infant receives the correct amount of medication.
D. Placing the medication in the back of the infant's throat using a dropper can cause gagging and aspiration. An oral syringe allows for better control and safer administration.

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A nurse is preparing to administer an enteral feeding to a preschooler who has a nasogastric tube. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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