A nurse is preparing to administer an enteral feeding to a preschooler who has a nasogastric tube. Which of the following actions should the nurse plan to take?
Discard residual fluid aspirated from the stomach prior to the feeding.
Administer the formula immediately after removing it from the refrigerator.
Elevate the head of the bed to a 45-degree angle.
Administer the feeding at a rate of 30 mL/min.
The Correct Answer is C
A. Residual fluid should not be discarded unless instructed by a healthcare provider, as it provides important information about gastric emptying and tolerance to previous feedings.
B. Formula should be brought to room temperature before administration to avoid causing discomfort or gastric irritation. Cold formula can cause cramps and slow gastric motility.
C. Elevating the head of the bed to a 45-degree angle helps prevent aspiration during feeding and promotes proper digestion. This position is critical for patient safety.
D. The feeding rate should be individualized based on the child's tolerance and prescribed regimen, and 30 mL/min is typically too fast for a preschooler, increasing the risk of aspiration or intolerance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sharing toys readily is more common in older preschoolers and school-age children.
B. Having an imaginary playmate typically occurs in children slightly older than 24 months.
C. Parallel play, where children play alongside each other without interacting, is typical for toddlers around 24 months.
D. Asking many questions is more characteristic of preschool-aged children.
Correct Answer is A
Explanation
A. Giving small amounts of oral rehydration solution frequently helps to prevent dehydration without overwhelming the child's stomach. This method is effective in rehydrating the child gradually and is well tolerated.
B. Fruit juices, especially those high in sugar, can worsen diarrhea and dehydration. They are not recommended for rehydration in cases of gastrointestinal infections.
C. While bananas and rice are part of the BRAT diet and can be included in meals, they do not address the immediate need for rehydration as effectively as oral rehydration solutions.
D. Promethazine is an antiemetic that is not typically indicated for mild dehydration and can have sedative side effects. Oral rehydration is the priority in managing mild dehydration.
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