The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?
Hold the infant with head and shoulders slightly elevated.
Use the syringe plunger to push formula at a rate of 5 ml/minute.
Microwave refrigerated formula to room temperature.
Measure and discard residual gastric contents before feeding.
The Correct Answer is A
Choice A reason: Holding the infant with head and shoulders slightly elevated helps prevent aspiration during feeding.
Choice B reason: Using the syringe plunger to push formula can increase the risk of aspiration and is not recommended.
Choice C reason: Microwaving formula can create hot spots and is not a safe method to warm formula.
Choice D reason: Measuring and discarding residual gastric contents is not typically recommended for routine feeding and can lead to improper assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A reason: Tinnitus is not an immediate concern in the context of multiple sclerosis.
Choice B reason: Tachycardia should be reported immediately as it could indicate an underlying cardiovascular issue or autonomic dysfunction.
Choice C reason: Tremors are a common symptom of multiple sclerosis and do not require immediate reporting unless there is a significant change.
Choice D reason: Paresthesia is also a common symptom of multiple sclerosis and does not require immediate reporting unless there is a significant change.
Choice E reason: Fever should be reported immediately as it can indicate an infection, which can exacerbate multiple sclerosis symptoms.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Checking the client's current fingerstick blood glucose is important to determine if the confusion and weakness are due to hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).
Choice B reason: Obtaining blood pressure and heart rate is useful for a general assessment but is secondary to assessing blood glucose levels in this scenario.
Choice C reason: Administering a PRN dose of regular insulin is not appropriate without first determining the client's blood glucose level. If the client is hypoglycemic, insulin could worsen the condition.
Choice D reason: Giving the client 4 ounces (120 mL) of orange juice is a quick way to raise blood sugar levels if the client is hypoglycemic.
Choice E reason: Providing diet carbonated soda is not effective for treating hypoglycemia because it does not contain sugar to raise blood glucose levels.
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