A nurse is preparing to administer a nasogastric (NG) tube feeding to a school-age child. Which of the following actions should the nurse plan to take?
Position the child at a 10° to 20° angle after feeding.
Measure the tubing from the nose to the distal port.
Warm the formula in the microwave.
Complete the feeding in 5 min.
The Correct Answer is B
Rationale:
A. Position the child at a 10° to 20° angle after feeding: This angle is too low to effectively reduce the risk of aspiration. The child should remain in at least a 30° to 45° upright position during and after feeding for optimal safety.
B. Measure the tubing from the nose to the distal port: Correct placement measurement involves determining the appropriate tube length from the tip of the nose to the earlobe and then to the xiphoid process. Measuring to the distal port ensures accurate placement for safe feeding.
C. Warm the formula in the microwave: Microwaving can create uneven heating and hot spots that may burn the gastrointestinal mucosa. Formula should be warmed by placing the container in warm water and checking the temperature before administration.
D. Complete the feeding in 5 min: Rapid feeding increases the risk of nausea, vomiting, and aspiration. Feedings should be administered slowly over the recommended time frame to allow for tolerance and digestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Putting on sterile gloves after preparing the sterile field: This is correct aseptic practice, as sterile gloves should be donned after the sterile field is prepared to maintain sterility.
B. Placing the supplies on the sterile field and leaving a 1-inch perimeter: Maintaining a 1-inch border around the sterile field is standard practice to avoid contamination. Supplies placed within the field but outside this border remain sterile.
C. Balancing the bottle on the sterile basin while pouring the liquid: Placing a bottle on a sterile field risks contaminating the field if the bottle is not sterile. This action constitutes a break in surgical aseptic technique.
D. Applying a sterile gown after applying a sterile mask: Donning a mask before the sterile gown is appropriate to prevent contamination of the sterile gown during placement. This does not break aseptic technique.
Correct Answer is A
Explanation
Rationale:
A. Wear a gown while providing personal hygiene: Contact precautions are required for clients with Clostridium difficile to prevent transmission via contaminated surfaces or direct contact. Wearing a gown during personal care protects the nurse’s clothing and skin from spores.
B. Place the client in a room with negative airflow: Negative airflow rooms are required for airborne infections such as tuberculosis or measles. C. difficile is spread via the fecal–oral route and does not require airborne isolation measures.
C. Apply a mask when providing care: Masks are necessary for droplet or airborne pathogens, but C. difficile spores are transmitted through direct or indirect contact, not respiratory droplets, so masks are not routinely required unless there is another indication.
D. Wipe the stethoscope with alcohol after leaving the client's room: C. difficile spores are resistant to alcohol-based disinfectants. Cleaning equipment requires soap and water or a sporicidal disinfectant to effectively remove spores and prevent spread.
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