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The nurse has mixed the formula with enteral nutritional formula powder to increase the caloric content to 24 calories per ounce (24 cal/30 mL).

Which nursing intervention(s) should the nurse include from the plan of care (POC) to help meet the client's nutritional needs? Select all that apply.

Feed the infant on demand.

Make sure the infant is well rested before feeds.

Wake the infant up to eat.

Feed for one-hour duration.

Initiate a three-hour feeding schedule.

Slowly increase caloric content using enteral nutritional formula powder.

Stroke the cheek to encourage sucking.

Give gavage feedings via percutaneous endoscopic gastrostomy (PEG) tube.

Answer and Explanation

Correct Answer : B,C,E,F,G

A. Infants with heart failure and failure to thrive require structured, energy-efficient feeding schedules rather than feeding on demand. Feeding on demand may lead to missed caloric goals and increased fatigue, as these infants often lack the energy reserves to signal hunger consistently.

B. Infants with heart failure tire easily due to increased metabolic demands and decreased cardiac efficiency. Ensuring the infant is rested before feeding helps conserve energy, allowing for more effective feeding and improved caloric intake.

C. Because of fatigue and poor endurance, these infants may sleep through feeding times and fail to meet nutritional needs. Waking the infant ensures adequate caloric intake and supports weight gain, which is critical in failure to thrive.

D. Prolonged feeding times increase energy expenditure, leading to more calorie loss than gain. Feeds should generally be limited to about 20–30 minutes to prevent fatigue and optimize energy conservation.

E. A structured feeding schedule (e.g., every 3 hours) ensures consistent caloric intake while allowing for rest periods. This approach helps balance nutritional needs with the infant’s limited energy reserves.

F. Increasing caloric density (e.g., from standard to 24–28 cal/oz) allows the infant to receive more calories in smaller volumes, which is essential for infants with fluid restrictions and fatigue. Gradual increases help prevent gastrointestinal intolerance.

G. Stimulating the rooting reflex by stroking the cheek promotes effective sucking and feeding, especially in infants who are fatigued or have weak feeding efforts. This helps maximize intake during limited feeding time.

H. A PEG tube is not a first-line intervention for this infant. Enteral tube feeding may be considered if oral intake is inadequate, but typically nasogastric (NG) feeding is used initially. PEG placement is invasive and reserved for long-term feeding issues.

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Correct Answer is ["30"]

Explanation

Step 1: Calculate total daily dose
Dose per administration = 50 mg
Frequency = 3 times/day
Total daily dose = 50 × 3 = 150 mg/day

Step 2: Use the formula
Volume (mL) = Total daily dose ÷ Concentration

Step 3: Insert values
= 150 ÷ 5

Step 4: Calculate
= 30 mL/day

A. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg. B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Viral meningitis whose temperature changed from 101° F (38.3° C) to 102° F (38.9° C). D. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.

Correct Answer is C

Explanation

A. A client with a subdural hematoma experiencing a significant change in blood pressure requires close monitoring and potentially urgent intervention. This patient’s condition is unstable and requires the assessment and clinical judgment of an RN, not a PN.

B. A client in myxedema coma with worsening hypotension is critically ill. The PN may assist with basic care, but managing hemodynamic instability in a life-threatening endocrine emergency requires RN-level assessment and intervention.

C. This is the most appropriate assignment for the PN. The client has viral meningitis with a mild temperature increase, indicating a relatively stable condition that requires monitoring and routine care rather than immediate complex interventions. The PN can safely perform tasks such as vital signs monitoring, basic neurological checks, and reporting changes to the RN.

D. A client with diabetic ketoacidosis (DKA) whose Glasgow Coma Scale score has decreased from 10 to 7 is showing signs of neurological deterioration and severe metabolic instability. This is an urgent, high-risk situation requiring RN-level assessment, critical thinking, and potentially rapid interventions such as fluid resuscitation, electrolyte replacement, and airway management. The PN should not be assigned this patient.

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The nurse has mixed the formula with enteral nutritional formula powder to increase the caloric content to 24 calories per ounce (24 cal/30 mL). Which nursing intervention(s) should the nurse include from the plan of care (POC) to help meet the client's nutritional needs? Select all that apply.

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An older client with an acute attack of gouty arthritis receives a prescription for indomethacin 50 mg PO three times a day. The client prefers an oral suspension which is available 5 mg/mL. How many mL should the nurse administer each day? (Enter numerical value only.)

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Explanation

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The nurse has mixed the formula with enteral nutritional formula powder to increase the caloric content to 24 calories per ounce (24 cal/30 mL).

Which nursing intervention(s) should the nurse include from the plan of care (POC) to help meet the client's nutritional needs? Select all that apply.