A nurse is providing teaching about the administration of gastrostomy tube feedings to the parents of an infant. Which of the following instructions should the nurse include?

Provide a pacifier for nonnutritive sucking.

Warm the formula in the microwave prior to administration.

Change the gastrostomy tube every 3 days.

Place the infant in a supine position after the feeding.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Provide a pacifier for nonnutritive sucking: Offering a pacifier promotes nonnutritive sucking, which supports oral motor development and provides comfort for the infant during gastrostomy tube feedings. This practice can help the infant transition more easily to oral feeding later.

B. Warm the formula in the microwave prior to administration: Warming formula in the microwave is unsafe because it can create hot spots that may burn the infant’s mouth or esophagus. Formula should be warmed using a bottle warmer or by placing the container in warm water.

C. Change the gastrostomy tube every 3 days: Routine gastrostomy tube replacement every 3 days is unnecessary and can cause trauma. Tubes are generally changed according to manufacturer recommendations or when malfunction or blockage occurs.

D. Place the infant in a supine position after the feeding: Infants should be kept in an upright or semi-upright position during and after feedings to reduce the risk of aspiration. Supine positioning increases the likelihood of reflux and respiratory complications.

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Correct Answer is D

Explanation

Rationale:
A. Instruct the client’s partner to assume care of the colostomy for the client: Having the partner take over care may reinforce the client’s avoidance and hinder acceptance of the stoma. The goal is to promote gradual involvement and self-care.

B. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing emotions can delay psychological adjustment. The nurse should instead encourage open discussion of feelings.

C. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: Transferring the client is unnecessary at this stage and may add emotional stress. Education and emotional support can be effectively provided in the current care setting.

D. Suggest the client join a support group for people who have colostomies: Support groups provide opportunities to share experiences with others who have undergone similar surgeries. Peer support can reduce isolation, promote acceptance, and help the client adapt to lifestyle changes more confidently.

A. Guide the client by walking parallel with them. B. Rearrange clients bedside table items frequently. C. Remove objects from client's path to the bathroom. D. Use a loud tone of voice when speaking with the client.

Correct Answer is C

Explanation

Rationale:
A. Guide the client by walking parallel with them: Clients with visual impairment should be guided by walking slightly ahead of them, allowing them to hold the nurse’s arm and follow safely. Walking parallel can limit spatial awareness and increase the risk of collision or falls.

B. Rearrange clients bedside table items frequently: Frequently moving personal items can confuse a client with reduced vision and increase the risk of injury. Maintaining a consistent environment promotes independence and safety.

C. Remove objects from client's path to the bathroom: Clearing pathways reduces the risk of trips and falls, which is essential for clients with impaired vision. Ensuring a clutter-free environment is a key safety intervention in the plan of care.

D. Use a loud tone of voice when speaking with the client: A louder voice is unnecessary unless the client has a hearing impairment. Communication should focus on clear, descriptive verbal guidance rather than volume, emphasizing orientation and safety.

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A nurse is providing teaching about the administration of gastrostomy tube feedings to the parents of an infant. Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

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