A nurse is preparing to administer an intermittent enteral feeding to a child who has an NG tube in place. Which of the following actions should the nurse take first?
Place the child in an upright position.
Verify the position of the NG tube.
Determine the gastric residual volume.
Flush the child's NG tube with sterile water.
The Correct Answer is B
Choice A reason:
The nurse should prioritize Choice B over Choice A as it is essential to first confirm the correct placement of the NG tube before proceeding with any other actions. If the tube is not correctly positioned, administering the enteral feeding can lead to potential complications, such as aspiration, which can be life-threatening. Therefore, it is crucial to ensure the NG tube's proper placement before moving forward with the feeding
Choice B reason:
This option takes precedence as verifying the NG tube's position is a fundamental step in the enteral feeding process. The nurse must use appropriate methods, such as X-ray or pH testing, to confirm that the tube is in the stomach and not in the respiratory tract or elsewhere. This verification ensures the safety and effectiveness of the feeding procedure and prevents potential harm to the child.
Choice C reason:
While checking the gastric residual volume (GRV) is an important step in some cases, it should be done after confirming the NG tube's proper placement (Choice B). GRV provides information about the amount of feeding left in the stomach and helps in assessing tolerance to the feeding. However, if the NG tube is misplaced, determining GRV becomes irrelevant as the feeding would not be going to the intended location.
Choice D reason:
Flushing the child's NG tube with sterile water is an appropriate step during the enteral feeding process but should be done after verifying the tube's position (Choice B). Flushing ensures that the tube is patent and free from any obstructions, allowing the feeding to pass through smoothly. However, again, if the NG tube is incorrectly positioned, flushing it would not address the underlying issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Insomnia may not be an expected finding in a school-age child with a newly diagnosed brain tumor. While sleep disturbances can occur due to various medical conditions, insomnia is not a common presenting symptom of brain tumors in this age group. Thus, it is less likely to be the correct answer.
Choice B reason:
A negative Babinski sign would actually be a normal finding in a school-age child. The Babinski sign is a neurological test that becomes positive in certain conditions, but a negative result is expected in a healthy child. Therefore, this finding is not indicative of a brain tumor and is not the correct choice.
Choice C reason:
Increased appetite is also an unlikely finding in a child with a newly diagnosed brain tumor. Brain tumors can lead to various neurological symptoms, but an increased appetite is not a characteristic feature. Thus, this choice is less likely to be correct.
Choice D reason:
Incoordination is a more expected finding in a school-age child with a newly diagnosed brain tumor. Brain tumors can affect motor skills and coordination due to their location and impact on the brain's functions. Children may experience difficulties with balance, coordination, and fine motor skills. Therefore, this choice is the most likely correct answer.
Correct Answer is A
Explanation
The nurse should maintain continuous observation of the adolescent.
Choice A reason:
The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.
Choice B reason:
Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.
Choice C reason:
Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.
Choice D reason:
Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.
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