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:
The client stating, "This test is to check if my baby has diabetes,” indicates a misunderstanding of the purpose of the 1-hr glucose tolerance test (GTT). The test is performed to screen for gestational diabetes in the mother, not to check the baby's diabetes status. Rationale: Gestational diabetes is a condition where high blood sugar levels develop during pregnancy, and it can affect both the mother and the baby's health.
Choice B reason:
The client mentioning, "If the result is higher than normal, I will need to be on insulin the rest of my life,” demonstrates a misconception about the implications of the 1-hr GTT. The 1-hr GTT is a preliminary screening test, and if the results are higher than normal, it indicates the need for further evaluation, but it does not immediately mean a lifetime dependence on insulin. Rationale: Insulin therapy may be required for managing gestational diabetes in some cases, but not necessarily for the rest of the mother's life.
Choice C reason:
The client saying, "If I forget and eat before the test, then I won't be able to have the test done,” indicates a misunderstanding of the test procedure. The 1-hr GTT requires fasting before the test, typically for 8 to 14 hours, to get accurate results. However, if the client mistakenly eats before the test, it doesn't mean they cannot have the test done at all; they may need to reschedule it after an appropriate fasting period. Rationale: Fasting is crucial for accurate glucose level measurement during the test.
Choice D reason:
The client stating, "If the results are high, then I need another test to see if I have gestational diabetes,” demonstrates a correct understanding of the 1-hr GTT. If the initial screening test shows elevated glucose levels, further testing, such as the 3-hour glucose tolerance test (GTT), is required to confirm the diagnosis of gestational diabetes. Rationale: The 3-hour GTT is a more comprehensive diagnostic test used to confirm or rule out gestational diabetes.
Correct Answer is C
Explanation
Choice A reason:
The nurse should not offer the child sips of clear liquids during a seizure. During a tonic-clonic seizure, the child's swallowing reflex may be impaired, and giving liquids could lead to aspiration or choking, causing further complications.
Choice B reason:
The nurse should not restrain the child during a seizure using both arms or any other means. Restraint can potentially lead to injury for both the child and the person attempting to restrain them. It is crucial to allow the child to move freely during the seizure to prevent harm.
Choice C reason:
Placing the child's head on a pillow is the correct choice. This positioning helps to protect the child's head from injury during the seizure. The pillow provides a cushioning effect, minimizing the risk of head trauma.
Choice D reason:
The nurse should not instruct the parent to give rectal diazepam to the child at the onset of the seizure unless specifically prescribed by the child's healthcare provider. Diazepam is a medication used to manage seizures, but its administration route and timing should be determined by the child's healthcare provider. Inappropriate use of medication can be dangerous and ineffective.
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