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. "My home has running water and electricity." This statement suggests adequate access to basic utilities, which supports hygiene and reduces risk for illness. It does not indicate a health risk.
B. "I eat vegetables directly from the field where I work." This poses a significant health risk due to potential pesticide exposure and contamination with harmful chemicals or microbes. Produce should be properly washed before consumption to reduce the risk of illness or poisoning.
C. "I wear a hat and long sleeves while I am working." This is a protective behavior, helping to reduce sun exposure, skin damage, and pesticide contact, and is not a health risk.
D. "I am currently sharing my home with two roommates." While crowded living conditions can pose some risk, this alone does not indicate a major health concern, especially if basic sanitation and ventilation are adequate.
Correct Answer is B
Explanation
A. The client calls the office multiple times per day to speak with their provider. This behavior may indicate anxiety or dependence, but it does not reflect rationalization, which involves making excuses to justify behavior.
B. The client states, "I only act this way because my partner makes me so angry." This is a clear example of rationalization, where the client is attempting to justify unacceptable behavior by blaming it on someone else rather than taking personal responsibility.
C. The client does not listen to the nurse during a discussion about their diagnosis. This may indicate denial or avoidance, not rationalization. The client may be overwhelmed and unwilling to accept the diagnosis.
D. The client reports that they get upset with their family members for "no apparent reason." This may suggest emotional dysregulation or projection, but it lacks the clear element of excuse-making that defines rationalization.
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