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. Checking the color and temperature of the toes helps assess for adequate circulation and potential complications like compartment syndrome.
B. Applying cushioning to the cast edges is important for comfort but is not the immediate priority.
C. Using a fan can help the cast dry faster but is not the priority action.
D. Repositioning the toddler is important to prevent pressure sores, but ensuring proper circulation takes precedence.

A. Administer meperidine to eliminate a fever. B. Decrease daily oral fluid intake. C. Maintain bed rest to prevent hypoxemia. D. Apply cold compresses to painful joints.

Correct Answer is C

Explanation

A. Meperidine is not recommended for pain management in sickle cell crisis due to the risk of seizures and neurotoxicity. Fever should be managed with antipyretics like acetaminophen.
B. Increasing, not decreasing, daily oral fluid intake is important to help reduce blood viscosity and prevent further sickling of red blood cells.
C. Maintaining bed rest helps to reduce oxygen demand and prevent hypoxemia, which can exacerbate the vaso-occlusive crisis.
D. Applying cold compresses is not recommended as it can cause vasoconstriction and worsen the pain. Warm compresses are more appropriate for managing pain in sickle cell crisis.

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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

A nurse is caring for a toddler who had a plaster spica cast applied 6 hr ago. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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