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?
Measure the tubing from the nose to the distal port.
Position the chud at a 10 to 20 angle after feeding.
Complete the feeding in 5 min.
Warm the formula in the microwave
The Correct Answer is A
A. Measure the tubing from the nose to the distal port. Proper placement of an NG tube requires measuring from the tip of the nose to the earlobe, then to the xiphoid process. This ensures the tube reaches the stomach without curling or entering the airway.
B. Position the child at a 10 to 20 angle after feeding. A head elevation of at least 30 to 45 degrees is necessary during and after NG feedings to reduce the risk of aspiration. A 10 to 20 degree angle is too low and unsafe for post-feeding positioning.
C. Complete the feeding in 5 min. NG feedings should be given slowly over 20 to 30 minutes to prevent gastrointestinal discomfort, cramping, or vomiting. A 5-minute infusion is too rapid and may overwhelm the child’s digestive capacity.
D. Warm the formula in the microwave. Microwaving formula can lead to uneven heating and hot spots, which pose a burn risk to the child. Formula should be warmed by placing the container in warm water and testing the temperature before administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Rotate staff members caring for the client. Clients with paranoid personality disorder often struggle with mistrust and feel suspicious of others. Consistency in staffing is important to build rapport and reduce anxiety, so rotating staff can worsen paranoia.
B. Speak in a neutral tone when addressing the client. This is appropriate because a calm, neutral, and non-threatening tone helps reduce perceived threats or suspicion. It promotes a sense of safety and control, which is important for therapeutic communication with paranoid individuals.
C. Limit the client's opportunities to socialize with others. While clients with paranoid personality disorder may prefer limited interaction, completely restricting socialization can increase isolation and reinforce delusional thinking. Structured, safe interactions are often encouraged.
D. Mix the medication with the client's food items. Administering medication without the client’s knowledge is deceptive and unethical, especially in someone already prone to distrust. Open and honest communication about treatment is crucial for promoting cooperation and trust.
Correct Answer is B
Explanation
A. Allow the second nurse to enter the data while observing them. Even if observed, allowing another person to use a computer while logged in under someone else’s credentials violates HIPAA and security policies.
B. Log off the computer and let the second nurse log on and enter the data. This is the correct and secure action. Each nurse must use their own login to ensure accountability and protect patient confidentiality, as required by HIPAA and institutional policies.
C. Ask the second nurse for the data and enter it for them. This may lead to documentation errors or confusion about who provided care. Each nurse should document their own assessments and interventions.
D. Tell the second nurse to enter the data when they return from their break. While delaying documentation is sometimes necessary, timely documentation is important for safe patient care. The second nurse should have the opportunity to chart promptly, but under their own credentials.
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