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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A slight fever is not typically expected after a lumbar puncture and could indicate an infection or other complication that needs to be addressed.
B. It is important to keep the child's head flat for several hours after the procedure to prevent post-lumbar puncture headaches and other complications.
C. Increasing fluid intake is encouraged after a lumbar puncture to help prevent headaches and promote recovery. Fluid restriction is not indicated.
D. Numbness in the legs is not a common side effect of a lumbar puncture. Any numbness or neurological changes should be reported immediately as they could indicate a complication.
Correct Answer is A
Explanation
A. Withdrawal can be a sign of trauma or distress, including sexual abuse.
B. While destructive behavior can be a reaction to various stressors, it is less specific to sexual abuse.
C. Perfectionistic behavior may be seen in children dealing with various pressures but is not specifically indicative of sexual abuse.
D. Manipulative behavior can be a response to different environmental factors and is not specifically indicative of sexual abuse.
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