A nurse is preparing to administer a tube feeding to a child who has an NG tube. Which of the following actions should the nurse take?
Connect a bulb attachment to the syringe to deliver the feeding.
Heat the formula to body temperature.
Position the child with the head of the bed elevated 15°.
Instill the feeding if the pH is less than 5.
The Correct Answer is C
Choice A reason:
Connecting a bulb attachment to the syringe is not a standard method for administering a tube feeding and can potentially lead to complications.
Choice B reason:
Heating the formula to body temperature is not typically necessary and can be potentially dangerous if it leads to overheating.
Choice C reason:
Positioning the child with the head of the bed elevated at 15° helps to prevent aspiration during tube feeding.
Choice D reason:
Instilling the feeding based on pH alone is not a sufficient criterion for administration. Other factors, such as radiographic confirmation of tube placement, should also be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
Correct Answer is A
Explanation
Choice A reason:
Using a bleach-based solution to clean the bedside table is an appropriate measure to prevent the spread of Clostridium difficile bacteria, as bleach is effective in killing spores.
Choice B reason:
While hand sanitizer is useful for killing many types of bacteria and viruses, it may not be as effective against Clostridium difficile spores. Washing hands with soap and water is preferred.
Choice C reason:
Placing the toddler in a negative-airflow room is not necessary for managing Clostridium difficile diarrhea. Standard precautions and proper hygiene are sufficient.
Choice D reason:
Loperamide is not typically recommended for managing Clostridium difficile diarrhea, as it may worsen the condition by slowing down the bowel motility. The primary treatment is discontinuing the antibiotic that caused the infection and, in some cases, using specific antibiotics to target the C. difficile bacteria.
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