A home health nurse is teaching a guardian about administering tube feedings to their 3-
month-old infant. Which of the following information should the nurse include in the teaching?

Allow the infant to suck on a pacifier during feedings.

Place enough formula for 12 hr in the feeding container.

Change the tube feeding setup every 36 hr.

Flush the tube with 30 mL of water between feedings.

Answer and Explanation

The Correct Answer is D

A. Allowing the infant to suck on a pacifier during tube feedings can lead to aspiration or choking and is not recommended.

B. Placing enough formula for 12 hours in the feeding container may lead to formula spoilage and contamination, as formula should be prepared fresh for each feeding.

C. Changing the tube feeding setup every 36 hours is not typically necessary unless there are signs of contamination or malfunction. The frequency of changing the setup should be based on institutional policies and manufacturer recommendations.

D. Flushing the tube with water before and after feedings helps ensure proper hydration and prevents tube blockage. A volume of 30 mL is commonly recommended for infants.

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Correct Answer is D

Explanation

A. Diminished bowel sounds are not typically indicative of fluid overload. They may suggest decreased gastrointestinal motility, but this finding alone does not specifically indicate fluid overload.

B. Bradycardia is not typically associated with fluid overload. Instead, tachycardia may occur as the body attempts to compensate for decreased cardiac output.

C. Hypotension may occur with fluid overload in severe cases, but it is not a consistent or specific finding. Other signs, such as bounding pulses, are more indicative of fluid overload.

D. Bounding pulses, or strong and forceful arterial pulses, can be a sign of fluid overload due to increased blood volume. This finding may be observed in clients receiving excessive enteral feedings or intravenous fluids.

A. The provider should renew the prescription for restraints every 48 hr. B. The nurse should pad the bony prominences. C. The nurse should tie the restraints using a square knot. D. The nurse should remove the restraints every 2 hr. E. The provider's prescription should include the type of restraint to use.

Correct Answer is ["B","D","E"]

Explanation

A. The provider should renew the prescription for restraints every 24 hours, not 48 hours.
B. Padding bony prominences helps prevent skin breakdown and pressure injuries.
C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in an emergency.
D. Removing the restraints every 2 hours allows for circulatory assessment, skin care, and range of motion exercises.
E. The provider's prescription should specify the type of restraint to ensure proper and appropriate use.

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A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is ["B","D","E"]

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A home health nurse is teaching a guardian about administering tube feedings to their 3-
month-old infant. Which of the following information should the nurse include in the teaching?