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 D

Explanation

A. "I will cover the catheter so he cannot see it."
Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.

B. "Let me provide more stimulation in his environment."
Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.

C. "Let's wait until tonight to see if he continues this behavior."
Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.

D. "I will call the doctor and get the prescription."
Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.

A. Bradycardia B. Flushed skin C. Decreased appetite D. Tremors

Correct Answer is D

Explanation

A. Bradycardia:
Low blood sugar levels can lead to bradycardia, a slower than normal heart rate.

B. Flushed skin:
Typically, low blood sugar levels might cause pallor or cool, clammy skin, rather than flushing.x

C. Decreased appetite:
Low blood sugar might result in increased hunger or a feeling of needing to eat rather than decreased appetite.

D. Tremors:
Hypoglycemia often presents with symptoms like tremors or shakiness due to the body's response to low blood sugar.

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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

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