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 D
Explanation
A. While loss of family income can contribute to stress and depression, it is not the highest risk factor for suicide.
B. Parental substance use disorder can increase the risk of suicidal behaviors in adolescents, but not as significantly as mental health disorders.
C. Parental divorce can be a stressor, but it is not the highest risk factor for suicide completion.
D. Bipolar disorder significantly increases the risk of suicide in adolescents due to the severe mood swings and potential for depressive episodes.
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.
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