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 B
Explanation
B. A PICC line is a long, flexible catheter inserted into a peripheral vein, typically in the upper arm, and advanced until the tip lies in the superior vena cava or the cavoatrial junction. PICC lines are suitable for long-term venous access and are often used for administering medications, including antibiotics, over several weeks or months. They offer stable and reliable access, reducing the need for frequent venipunctures.
A. Butterfly needles are typically used for short-term venous access, such as for blood draws or administering medications that do not require long-term therapy. They are not suitable for prolonged use or for administering medications over several weeks, as they are not designed for secure and stable access over an extended period.
C. A peripheral IV-lock, also known as a saline lock or heplock, is a short catheter inserted into a peripheral vein and then capped off for intermittent use. While peripheral IV-locks are suitable for short-term venous access, they are not ideal for prolonged therapy lasting several weeks. Additionally, they may not provide the necessary stability and reliability for administering IV antibiotics over an extended period.
D. A small gauge peripheral angiocath refers to a short catheter inserted into a peripheral vein for intravenous access. While a larger gauge catheter, such as a 16-gauge, may allow for faster infusion rates and is suitable for certain situations requiring rapid fluid administration, it may not be the most appropriate choice for long-term IV antibiotic therapy. The choice of gauge depends on factors such as the client's vein size, the viscosity of the medication, and the duration of therapy.
Correct Answer is A
Explanation
A. Isotonic solutions have a similar osmolarity to that of blood plasma, meaning they exert the same osmotic pressure as blood. This equilibrium prevents the movement of water across cell membranes, thereby maintaining cell volume and preventing cellular dehydration or swelling. Examples of isotonic solutions commonly used for intravenous fluid replacement include 0.9% saline (normal saline) and lactated Ringer's solution.
B. Hypotonic solutions have a lower osmolarity than blood plasma, meaning they exert less osmotic pressure than blood. When administered, hypotonic solutions cause water to move into cells, leading to cellular swelling. While hypotonic solutions can help hydrate cells and replenish intracellular fluid, they are not typically used for rapid volume replacement because they can exacerbate extracellular fluid deficits and cause complications such as cerebral edema or cardiovascular collapse.
C. Hypertonic solutions have a higher osmolarity than blood plasma, meaning they exert greater osmotic pressure than blood. When administered, hypertonic solutions cause water to move out of cells, leading to cellular shrinkage. Hypertonic solutions are often used to expand intravascular volume in cases of severe hypovolemia or shock, as they rapidly increase blood osmolarity and draw fluid from the interstitial space into the bloodstream. Examples of hypertonic solutions include 3% saline and 5% dextrose in 0.9% saline.
D. Hyperosmotic solutions have an elevated osmolarity compared to blood plasma, indicating a higher concentration of solutes. These solutions exert osmotic pressure that draws water out of cells, leading to cellular dehydration. While hyperosmotic solutions are not commonly used for rapid volume replacement due to their pot
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