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 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.
Correct Answer is ["A","B","D"]
Explanation
A. Covering the scale with a clean sheet of paper is unnecessary and does not affect the accuracy of the weight or length measurement.
B. Measuring the infant's length from the crown of the head to the heels of the feet is the correct method for obtaining length measurements in infants.
C. Placing a stadiometer on the top of the infant's head is incorrect; the measurement should be taken from head to heel.
D. Ensuring the scale is balanced to "0" before weighing the infant is essential for obtaining an accurate weight measurement.
E. Obtaining the infant's weight with their diaper on may add unnecessary weight, potentially affecting the accuracy of the weight measurement.
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