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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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Increasing the wound VAC suction may help with drainage but does not address the underlying issue that might require specialist evaluation.

Choice B reason: Consulting the wound care specialist to evaluate the wound ensures that the client receives expert assessment and appropriate recommendations for care.

Choice C reason: Cleansing the wound and discontinuing the VAC system is not an appropriate action without specialist input.

Choice D reason: Reapplying the VAC system after irrigating away drainage may be necessary, but it should be done based on the specialist’s recommendations.

Choice E reason: Documenting the wound measurements with tunneling is important for record-keeping but does not address the immediate issue of evaluating the wound.

A. Activity intolerance. B. Fluid volume excess. C. Ineffective airway clearance. D. Altered nutrition; less than body requirements.

Correct Answer is C

Explanation

Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.

Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.

Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.

Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.

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The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a non-healing wound and excessive drainage is using a wound VAC system. The nurse notices increased drainage and signs of possible infection. What is the most appropriate nursing intervention?

Correct Answer is B

Explanation

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Correct Answer is C

Explanation

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