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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: Evaluating a client's mobility progress involves assessment and clinical judgment, which are beyond the scope of practice for a UAP.

Choice B reason: Titrating oxygen requires clinical judgment and understanding of the client's condition, which should be performed by licensed nursing staff.

Choice C reason: Procuring platelet products from the blood bank is within the scope of practice for a UAP as it involves following protocols and retrieving items, not direct patient care.

Choice D reason: Determining the diameter and depth of a client's dermal ulcer involves assessment and clinical judgment, which should be performed by licensed nursing staff.

A. Increase the wound VAC suction to eliminate the drainage. B. Consult the wound care specialist to evaluate the wound. C. Cleanse the wound and discontinue the VAC system. D. Reapply the VAC system after irrigating away drainage. E. Document the wound measurements with tunneling.

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.

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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

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Explanation

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Correct Answer is B

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