A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. (Move the steps, placing them in the selected order of performance. All steps must be used.)
Verify tube placement
Check the residual feeding contents
Evaluate tolerance of feeding
Administer the feeding
The Correct Answer is A,B,D,C
A. Verify tube placement: This is the first step to ensure that the tube is in the correct position and not in the lungs, which could lead to aspiration.
B. Check the residual feeding contents: This helps to assess gastric emptying and ensure that the stomach can tolerate the feeding. If there is a large amount of residual, the feeding may be delayed or the rate may need to be adjusted.
D. Administer the feeding: Once tube placement is confirmed and residual contents are assessed, the feeding can be administered at the prescribed rate.
C. Evaluate tolerance of feeding: After the feeding is complete, it's important to monitor the client for signs of tolerance, such as the absence of nausea, vomiting, or abdominal distension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The recommendation to introduce whole milk is typically at 12 months of age. By this time, the infant's digestive system is mature enough to handle whole milk, and they have likely begun eating a variety of solid foods. Whole milk provides essential nutrients such as calcium and vitamin D, which are important for the child’s development at this stage.
B. At 10 months, the infant is still primarily reliant on breast milk or formula for their nutritional needs. Introducing whole milk before 12 months is generally not recommended because the infant's digestive system might not be fully developed to handle whole milk, and it may not provide adequate nutrition compared to breast milk or formula.
C. At 8 months, the infant is usually beginning to explore solid foods but is still dependent on breast milk or formula for the majority of their nutrition. Whole milk is not recommended at this age as the infant’s digestive system is not yet mature enough to handle it, and the nutritional needs are best met with breast milk or formula.
D. By 6 months, infants are typically starting to be introduced to solid foods but should continue receiving breast milk or formula as their primary source of nutrition. Whole milk is not recommended at this age as the infant’s kidneys and digestive system are not fully developed to process it.
Correct Answer is C
Explanation
A. This device is used to prevent hip rotation and adduction. It is placed along the lateral side of the client's hips to keep the hips in a neutral position, preventing external rotation and adduction. It does not specifically address plantar flexion contractures of the feet.
B. This device is used primarily to reduce pressure and prevent heel ulcers, not to prevent plantar flexion contractures. Sheepskin pads provide cushioning to prevent pressure sores, but they do not help in maintaining the proper position of the feet to prevent contractures.
C. This is the appropriate device for preventing plantar flexion contractures. A footboard is placed at the end of the bed to keep the feet in a dorsiflexed position, preventing them from curling downward. It helps maintain the feet in a neutral or slightly dorsiflexed position, thus preventing plantar flexion contractures.
D. This device is used to maintain the hips in an abducted position, typically following hip surgery. It prevents the legs from coming together and helps with hip alignment but does not address the issue of plantar flexion contractures.
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