A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?

Replace the NG tube.

Lower the head of the bed to 15°.

Slow the rate of formula instillation.

Chill and readminister the formula.

Answer and Explanation

The Correct Answer is C

A. Replace the NG tube.: There is no indication that the NG tube is malfunctioning or misplaced in this case. The cramping and nausea are more likely related to the feeding itself, not the tube.

B. Lower the head of the bed to 15°.: Lowering the head of the bed would increase the risk of aspiration. The head of the bed should be elevated during enteral feeding to reduce this risk.

C. Slow the rate of formula instillation.: Abdominal cramping and nausea during enteral feeding can occur if the feeding rate is too fast. Slowing the rate allows the stomach to better tolerate the formula and can alleviate symptoms.

D. Chill and readminister the formula.: The temperature of the formula should not cause the cramping or nausea. Feeding should be administered at room temperature or as directed by protocol, and re-chilling it is unlikely to help with the symptoms.

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Correct Answer is B

Explanation

A. "It takes 2 months of scheduled use before this medication is effective." is incorrect. Montelukast is generally effective within 1-2 weeks of starting the medication, not 2 months.

B. "I will give this medication to my child once daily in the evening." is correct. Montelukast is usually administered once daily, in the evening, to help prevent asthma symptoms.

C. "I can stop giving my child this medication if he is taking a steroid." is incorrect. Montelukast and steroids can be used together to manage asthma, but stopping montelukast is not recommended unless advised by the healthcare provider.

D. "I will give this medication to my child every 2 hours if he is wheezing." is incorrect. Montelukast is a maintenance medication and should not be used as a rescue treatment for acute wheezing. For acute symptoms, a short-acting bronchodilator is typically used.

A. Expresses conflict over independence and control B. Demonstrates self-centered thinking C. Displays emotional detachment from parents D. Grasps concept of cause-and-effect

Correct Answer is D

Explanation

A. Expressing conflict over independence and control is incorrect. This behavior is more characteristic of adolescents, who struggle with autonomy as they develop their identity. Nine-year-old children are still largely influenced by parents and rules.

B. Demonstrating self-centered thinking is incorrect. Egocentric thinking is typical in preschool-aged children, while school-aged children develop the ability to see other perspectives and think more logically.

C. Displaying emotional detachment from parents is incorrect. While school-aged children begin to form peer relationships, they typically maintain strong emotional connections with their parents rather than detaching from them.

D. Grasping the concept of cause-and-effect is correct. At this stage, children develop logical thinking and an understanding of consequences, allowing them to recognize how actions lead to specific outcomes.

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A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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