A nurse is caring for an infant who receives intermittent enteral feedings through a gastrostomy tube.
Which of the following actions should the nurse take when administering a feeding? (Select all that apply.).
Offer the infant a pacifier during feedings.
Check for residual volumes by aspirating stomach contents.
Place the infant in supine position.
Instill the formula over a period of 30 to 45 min.
Heat the formula to 39° C (102° F) prior to administration.
Correct Answer : A,B,D
A. Offer the infant a pacifier during feedings.
B. Check for residual volumes by aspirating stomach contents.
D. Instill the formula over a period of 30 to 45 min.
Offering the infant a pacifier during feedings can help promote non-nutritive sucking and provide comfort to the infant.
Checking for residual volumes by aspirating stomach contents can help monitor gastric emptying and tolerance to enteral feeding.
Instilling the formula over a period of 30 to 45 min can help prevent overfeeding and reduce the risk of aspiration.
Choice C is wrong because placing the infant in a supine position during feedings increases the risk of aspiration.
The infant should be placed in an upright or semi-upright position during feedings.
Choice E is wrong because heating the formula to 39° C (102° F) prior to administration is not necessary and may even be harmful if the formula is overheated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
The first action the nurse should take is to elevate the child’s leg.
This is choice A. Elevating the child’s leg can help reduce swelling and improve circulation.
After elevating the child’s leg, the nurse can then administer pain medication (choice B), petal the edges of the cast (choice C), and teach the child about cast care (choice D).
Correct Answer is A
Explanation
A decrease in peripheral edema is an indication that the furosemide medication is effective.
Furosemide is a diuretic that helps to reduce fluid buildup in the body, including peripheral edema, which is a common symptom of heart failure.
Choice B is wrong because furosemide does not directly decrease cardiac output.
Choice C is wrong because furosemide does not increase venous pressure.
Choice D is wrong because furosemide can actually cause a decrease in potassium levels, not an increase.
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