A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?

"I will allow the position my mother finds most comfortable during the feeding."

"I will turn my mother on her left side during the feeding."

"I will position the head of the bed 45 degrees during the feeding."

"I will elevate the head of the bed 10 degrees during the feeding."

Answer and Explanation

The Correct Answer is C

A. "I will allow the position my mother finds most comfortable during the feeding."
This statement does not provide specific guidance on the proper positioning for enteral feedings. It's important to follow recommended positions to prevent complications.

B. "I will turn my mother on her left side during the feeding."
Turning the client on the left side is not a recommended position for enteral feedings. The head of the bed is usually elevated to 30-45 degrees to prevent aspiration.

C. "I will position the head of the bed 45 degrees during the feeding."
This is the correct choice. Elevating the head of the bed to 45 degrees helps prevent aspiration and facilitates proper flow of enteral feedings into the stomach.

D. "I will elevate the head of the bed 10 degrees during the feeding."
While some elevation is better than lying flat, the recommended angle is usually 30-45 degrees to minimize the risk of regurgitation and aspiration.

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Correct Answer is ["C","D"]

Explanation

A. The patient uses crutches with a swing-to gait.
This action doesn't necessarily indicate a concern after hip arthroplasty. However, the nurse might want to assess the patient's gait and the use of crutches to ensure the proper technique is being employed and that the patient feels comfortable and stable.

B. The patient sits straight up on the edge of the bed.
Sitting straight up on the edge of the bed may not be suitable immediately after hip arthroplasty, especially with the posterior approach. The nurse should assess the patient's ability to sit upright without putting excessive pressure or strain on the surgical site.

C. The patient bends over the sink while brushing teeth.
Bending over can put stress on the surgical site and should be avoided during the initial recovery period after hip arthroplasty. This action might strain the incision and affect the healing process.

D. The patient leans over to pull on shoes and socks.
Similar to bending over the sink, leaning over to put on shoes and socks can strain the hip joint and surgical site. This movement could potentially put stress on the incision and hinder the healing process.

A. BMI of 20 B. Peripheral neuropathy C. Immobility D. Hypoperfusion E. Prealbumin level of 16 mg/dL

Correct Answer is ["B","C","D","E"]

Explanation

A. BMI of 20:
A BMI of 20 is within the normal range. While extremes of BMI, either low or high, can contribute to health issues, a BMI of 20 alone may not significantly increase the risk of pressure injuries.

B. Peripheral neuropathy:
Peripheral neuropathy, which involves damage to the nerves in the extremities, can lead to decreased sensation and awareness. Clients with peripheral neuropathy may have difficulty sensing pressure, friction, or discomfort, making them more susceptible to pressure injuries.

C. Immobility:
Immobility is a significant risk factor for pressure injuries. Clients who are unable to change positions frequently are more likely to develop pressure points, particularly over bony prominences. Regular repositioning is essential to prevent pressure injuries in immobile individuals.

D. Hypoperfusion:
Hypoperfusion, or inadequate blood flow to tissues, can compromise tissue viability. Proper blood circulation is crucial for delivering oxygen and nutrients to the skin and underlying tissues. Impaired perfusion can contribute to tissue damage and increase the risk of pressure injuries.

E. Prealbumin level of 16 mg/dL:
Prealbumin is a marker of nutritional status. A low prealbumin level (16 mg/dL) indicates malnutrition, which can impair the body's ability to repair and maintain tissues, including the skin. Malnourished individuals are at an increased risk of developing pressure injuries.

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A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?

Correct Answer is ["C","D"]

Explanation

A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?

Correct Answer is ["B","C","D","E"]

Explanation

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