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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 C

Explanation

Choice A reason: Yellow expectorated sputum is indicative of an infection but does not require immediate intervention.

Choice B reason: An oral temperature of 100.5°F (38.1°C) suggests a mild fever, common with infections and manageable with antipyretics.

Choice C reason: Bilateral diffuse wheezing is a sign of airway obstruction and requires immediate intervention to ensure the client's airway remains open and they are able to breathe effectively.

Choice D reason: Shortness of breath on exertion is expected in clients with COPD and pneumonia but does not require the most immediate intervention compared to wheezing.

A. Observe the appearance of the client's urine. B. Measure the girth of the client's lower abdomen. C. Auscultate an area six inches below the umbilicus. D. Palpate the area above the pubic symphysis.

Correct Answer is D

Explanation

Choice A reason: Observing the appearance of urine can provide information but is not the most direct assessment for urinary retention.

Choice B reason: Measuring the girth of the lower abdomen is not a specific assessment for urinary retention.

Choice C reason: Auscultation is not a reliable method for assessing urinary retention.

Choice D reason: Palpating above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is D

Explanation

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