A nurse is about to administer a bolus enteral feeding to a client who is on bedrest. How does the nurse position the client during the feeding?
On left side, with the knees bent
With the head of the bed elevated 30-45 degrees
On the right side, with a pillow behind the back
With the head of the bed elevated 15 degree
The Correct Answer is B
B. Elevating the head of the bed to 30-45 degrees is the recommended position for administering enteral feeding to reduce the risk of aspiration. This semi-upright position helps promote gastric emptying and reduces the likelihood of reflux or regurgitation of the feed into the lungs. It also allows for better tolerance of the feeding and minimizes the risk of complications.
A. Positioning the client on the left side with the knees bent is not typically recommended for enteral feeding. This position may increase the risk of aspiration, especially if the client has impaired swallowing or if there are issues with gastric emptying. It may also not be the most comfortable or practical position for administering enteral feeding.
C. Positioning the client on the right side with a pillow behind the back is not a standard practice for administering enteral feeding. This position may not provide optimal access for administering the feed, and it does not offer the benefits of head elevation to reduce the risk of aspiration.
D. Elevating the head of the bed to only 15 degrees may not provide sufficient upright positioning to reduce the risk of aspiration during enteral feeding. While it is better than lying completely flat, a higher degree of elevation (30-45 degrees) is generally recommended for optimal safety and effectiveness of enteral feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. This action could pose a significant liability risk as it violates the standard of care, which includes providing thorough and accurate handoff communication to ensure continuity of care. Failing to provide a report before transferring a client to ICU could lead to miscommunication, errors in treatment, and compromised patient safety.
C. Documenting vital signs taken by another nurse is generally acceptable as long as the nurse ensures the accuracy of the information and documents according to institutional policies and standards. However, if the nurse knowingly documents false or inaccurate vital signs, it could pose a liability risk.
E. Using equipment with a frayed cord poses a significant liability risk as it could lead to electrical hazards, equipment malfunction, or patient injury. Nurses have a duty to ensure the safety and integrity of equipment used in patient care and should promptly report any defects or safety concerns to prevent harm to patients.
B. Completing the admission assessment is a standard nursing responsibility and is not inherently a liability risk. However, liability could arise if the assessment is incomplete, inaccurate, or not documented appropriately, leading to errors in care or failure to identify and address the client's needs
D. Calling the physician to request an order for pain medication is a routine nursing responsibility and is not inherently a liability risk. However, liability could arise if the nurse fails to communicate important information about the client's condition or medication history, resulting in inappropriate or unsafe prescribing practices.
Correct Answer is A
Explanation
A. Confidentiality refers to the ethical duty of healthcare providers to safeguard patient information and maintain privacy. Upholding confidentiality means that healthcare providers must not disclose sensitive information about a patient to unauthorized individuals without the patient's consent. In this scenario, if the client asks the nurse not to disclose their medical diagnosis to their family members, respecting this request would uphold the principle of confidentiality by protecting the privacy of the patient's health information.
B. Justice in healthcare refers to the fair and equitable distribution of resources and the provision of healthcare services. While justice is an important ethical principle, it is not directly applicable to the client's request regarding the disclosure of their medical diagnosis to their family members.
C. Veracity, also known as truthfulness, is the ethical principle of honesty and truthfulness in communication with patients. Upholding veracity means providing patients with accurate and truthful information about their health condition and treatment options. In this scenario, if the nurse complies with the client's request not to disclose their medical diagnosis to their family members, it may involve withholding information and not fully disclosing the truth to the family members. Therefore, upholding the client's request may conflict with the principle of veracity.
D. A healthcare proxy is a legal document that allows an individual (the proxy) to make healthcare decisions on behalf of another person (the principal) if the principal is unable to make decisions for themselves. The existence of a healthcare proxy does not directly relate to the client's request regarding the disclosure of their medical diagnosis to their family members.
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