Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an infant who receives intermittent enteral feedings through a gastrostomy tube.
Which of the following actions should the nurse take when administering a feeding? (Select all that apply.).
A. Offer the infant a pacifier during feedings.
Offering the infant a pacifier during feedings can help promote non-nutritive sucking and provide comfort to the infant.
B. Check for residual volumes by aspirating stomach contents.
Checking for residual volumes by aspirating stomach contents can help monitor gastric emptying and tolerance to enteral feeding.
C. Place the infant in supine position.
Choice C is wrong because placing the infant in a supine position during feedings increases the risk of aspiration. The infant should be placed in an upright or semi-upright position during feedings.
D. Instill the formula over a period of 30 to 45 min.
Instilling the formula over a period of 30 to 45 min can help prevent overfeeding and reduce the risk of aspiration.
E. Heat the formula to 39° C (102° F) prior to administration.
Choice E is wrong because heating the formula to 39° C (102° F) prior to administration is not necessary and may even be harmful if the formula is overheated.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Nursing Care of Children 2019 Proctored Exam. Take the full exam now
Full Explanation
A. Offer the infant a pacifier during feedings.
B. Check for residual volumes by aspirating stomach contents.
D. Instill the formula over a period of 30 to 45 min.
Offering the infant a pacifier during feedings can help promote non-nutritive sucking and provide comfort to the infant.
Checking for residual volumes by aspirating stomach contents can help monitor gastric emptying and tolerance to enteral feeding.
Instilling the formula over a period of 30 to 45 min can help prevent overfeeding and reduce the risk of aspiration.
Choice C is wrong because placing the infant in a supine position during feedings increases the risk of aspiration.
The infant should be placed in an upright or semi-upright position during feedings.
Choice E is wrong because heating the formula to 39° C (102° F) prior to administration is not necessary and may even be harmful if the formula is overheated.
Similar Questions
A nurse is caring for a school-age child following the application of a cast to a fractured right tibia.
Which of the following actions should the nurse take first?
A. Elevate the child's leg.
The first action the nurse should take is to elevate the child’s leg. This is choice A. Elevating the child’s leg can help reduce swelling and improve circulation. After elevating the child’s leg, the nurse can then administer pain medication (choice B), petal the edges of the cast (choice C), and teach the child about cast care (choice D).
B. Administer pain medication.
C. Petal the edges of the cast.
D. Teach the child about cast care.
Full Explanation
The first action the nurse should take is to elevate the child’s leg.
This is choice A. Elevating the child’s leg can help reduce swelling and improve circulation.
After elevating the child’s leg, the nurse can then administer pain medication (choice B), petal the edges of the cast (choice C), and teach the child about cast care (choice D).
A nurse is caring for a 3-month-old infant who has a cleft of the soft palate.
Which of the following actions should the nurse take?
A. Discontinue feeding if the infant's eyes become watery.
Choice A is wrong because watery eyes are not an indication to discontinue feeding.
B. Postpone burping the infant until after completing each feeding.
Choice B is wrong because babies with cleft palate should be burped more frequently, but not so often as to interrupt good feeding behaviors.
C. Elevate the infant's head to a 10° angle during feedings.
The correct answer is choice C. Elevate the infant’s head to a 10° angle during feedings. This position can help prevent milk from coming out of the infant’s nose and reduce the risk of choking.
D. Feed the infant 177.4 mL (6 oz) of formula three times each day.
Choice D is wrong because the amount of formula an infant needs varies and should be determined by a pediatrician.
E. Feed the infant 177.4 mL (6 oz) of formula three times each day.
Full Explanation
The correct answer is choice C. Elevate the infant’s head to a 10° angle during feedings.
This position can help prevent milk from coming out of the infant’s nose and reduce the risk of choking.
Choice A is wrong because watery eyes are not an indication to discontinue feeding.
Choice B is wrong because babies with cleft palate should be burped more frequently, but not so often as to interrupt good feeding behaviors.
Choice D is wrong because the amount of formula an infant needs varies and should be determined by a pediatrician.
A nurse is teaching a group of female adolescents about healthy eating. Which of the following instructions should the nurse include in the teaching?
A. "Limit your sodium intake to 3,000 milligrams per day."
Choice A is wrong because the American Heart Association recommends limiting sodium intake to 1,500 milligrams per day.
B. "Consume 1,500 to 1,700 calories per day."
Choice B is wrong because caloric needs vary depending on age, sex, height, weight, and level of physical activity.
C. "Increase the amount of your dietary iron intake."
During menstruation, girls lose some iron and should try to replace it by including iron-rich foods in their diet.
D. "Decrease your vitamin D intake once you start to menstruate.”
Choice D is wrong because vitamin D is important for bone health and adolescents should not decrease their intake.
Full Explanation
During menstruation, girls lose some iron and should try to replace it by including iron-rich foods in their diet.
Choice A is wrong because the American Heart Association recommends limiting sodium intake to 1,500 milligrams per day.
Choice B is wrong because caloric needs vary depending on age, sex, height, weight, and level of physical activity.
Choice D is wrong because vitamin D is important for bone health and adolescents should not decrease their intake.