A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?
Label the feeding bag with the date and time of the start of the feeding.
Aspirate the client's stomach contents.
Hang the feeding bag 30 cm (12 inches) above the client.
Warm the feeding to room temperature.
The Correct Answer is B
Choice A reason:Labeling the feeding bag with the date and time is important for tracking, but it is not the first action to take. The priority is to ensure that the NG tube is correctly placed and the stomach contents can be aspirated to verify placement before administering the feeding.
Choice B reason:Aspirating the client's stomach contents is the first action the nurse should take. This is to confirm the correct placement of the NG tube to prevent complications such as aspiration pneumonia. It is a critical step before starting any enteral feeding.
Choice C reason: Hanging the feeding bag 30 cm (12 inches) above the client is necessary for gravity feeding, but it comes after verifying the NG tube placement through aspiration of stomach contents.
Choice D reason:Warming the feeding to room temperature is a comfort measure and helps to prevent gastrointestinal discomfort. However, it is not the first action to take. The priority is to check the tube placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.2"]
Explanation
- Step 1: Identify the child's weight in pounds. The child weighs 33 lbs.
- Step 2: Convert the child's weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, 33 lbs = 33 ÷ 2.2 kg. Calculating the division gives us approximately 15 kg.
- Step 3: Identify the prescribed dose in mcg/kg/day. The child is scheduled to receive 8 mcg/kg/day of digoxin, divided equally every 12 hours.
- Step 4: Calculate the total daily dose in mcg. We can do this by multiplying the child's weight in kg by the prescribed dose in mcg/kg:
- Total daily dose = 8 mcg/kg/day × 15 kg.
- Calculating the multiplication gives us: Total daily dose = 120 mcg/day.
- Step 5: Since the dose is divided equally every 12 hours, we divide the total daily dose by 2 to get the dose per administration:
- Dose per administration = Total daily dose ÷ 2.
- Dose per administration = 120 mcg ÷ 2.
- Calculating the division gives us: Dose per administration = 60 mcg.
- Step 6: Identify the concentration of the available solution. The available solution contains 0.05 mg/mL of digoxin. Convert this to mcg/mL for consistency with the dose per administration. We know that 1 mg = 1000 mcg. So, 0.05 mg = 0.05 × 1000 mcg = 50 mcg/mL.
- Step 7: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 50 mcg is to 1 mL as 60 mcg is to X mL.
- In other words, 50 mcg : 1 mL = 60 mcg : X mL.
- Step 8: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 50 mcg × X mL = 60 mcg × 1 mL.
- Simplifying this gives us: 50X = 60.
- Dividing both sides by 50 gives us: X = 60 ÷ 50.
- Calculating the division gives us: X = 1.2.
Administer 1.2 mL of the digoxin elixir per dose.
Correct Answer is A
Explanation
Choice A reason:Providing oral care every 4 hours and as needed is an evidence-based practice to lower the risk of ventilator-associated pneumonia by minimizing the buildup of bacteria in the mouth³.
Choice B reason:Positioning the head of the client's bed in the flat position is not recommended as it can increase the risk of aspiration; elevating the head of the bed to 30° to 45° is the standard practice.
Choice C reason:Turning the client every 4 hours is important for preventing pressure ulcers and improving lung function but is not the primary action for reducing pneumonia risk³.
Choice D reason:Providing humidity helps to maintain mucous membrane integrity but must be carefully managed to prevent bacterial growth and is not the primary action for reducing pneumonia risk³.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.