A nurse is caring for a client whose hand movement is limited. What action should the nurse take to assist the client with feeding?

Provide an adaptive feeding device for the client.

Place the client in a lateral position.

Arrange the food groups clockwise on the plate.

Initiate a liquid diet for the client.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: Provide an adaptive feeding device for the client.

Choice A rationale: Providing an adaptive feeding device, such as a built-up utensil or a swivel spoon, can help clients with limited hand movement feed themselves independently. These devices are designed to make grasping and manipulating utensils easier, promoting independence and self-care.

Choice B rationale: Placing the client in a lateral position might not directly address the issue of limited hand movement, and it could even make feeding more challenging. This position is typically used for clients with swallowing difficulties or those at risk of aspiration.

Choice C rationale: Arranging food groups clockwise on the plate may help clients with visual impairments or cognitive issues, but it would not directly assist a client with limited hand movement during feeding.

Choice D rationale: Initiating a liquid diet for the client is not the most appropriate initial action to address limited hand movement. This might be considered as a last resort if the client is unable to feed themselves with any type of adaptive device or assistance. The priority should be promoting independence and providing appropriate tools to support self-feeding.

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Correct Answer is B

Explanation

Choice A rationale
While it’s true that a nasal cannula allows the patient to remove it for a while when it gets uncomfortable, this is not the primary reason for using a nasal cannula. The main purpose of a nasal cannula is to deliver oxygen.
Choice B rationale
A nasal cannula delivers the low concentration of oxygen that the patient needs. It is designed to provide a specific amount of oxygen, and the flow rate can be adjusted as needed.

Choice C rationale
While a nasal cannula does deliver a specific concentration of oxygen, it does not do so constantly. The amount of oxygen delivered can vary depending on the patient’s breathing rate and depth.
Choice D rationale
A nasal cannula does not deliver the highest concentration of oxygen possible. Other devices, such as non-rebreather masks, can deliver higher concentrations of oxygen.

A. “I will call the doctor and get the prescription.”. B. “I will cover the catheter so he cannot see it.”. C. “Let me provide more stimulation in his environment.”. D. “Let’s wait until tonight to see if he continues this behavior.”.

Correct Answer is A

Explanation

Choice A rationale
The nurse should prioritize the safety of the patient. If a patient is frequently attempting to remove his feeding tube, it could lead to complications such as infection or injury. Therefore, the nurse might need to consider using a restraint as a last resort. However, it’s important to note that restraints should only be used when all other alternatives have been explored and failed. These alternatives include having staff or a family member sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications.
Choice B rationale
Covering the catheter so the patient cannot see it might not be effective if the patient is aware of its presence and is determined to remove it. This approach does not address the underlying issue and may not prevent the patient from attempting to remove the feeding tube.
Choice C rationale
Providing more stimulation in the patient’s environment might be helpful in some cases, but it may not prevent the patient from attempting to remove the feeding tube. The effectiveness of this approach would depend on the specific circumstances and the patient’s condition.
Choice D rationale
Waiting until tonight to see if the patient continues this behavior could potentially put the patient at risk. If the patient is frequently attempting to remove the feeding tube, immediate action may be necessary to ensure the patient’s safety.

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A nurse is caring for a client whose hand movement is limited. What action should the nurse take to assist the client with feeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is undergoing oxygen therapy through a nasal cannula.If the patient inquires about the reason for having oxygen tubing in their nose, what explanation about the cannula should the nurse provide?

Correct Answer is B

Explanation

A nurse is caring for a patient who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?

Correct Answer is A

Explanation

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