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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Correct answer: D
A.While it is important to ensure the can of formula is clean, it should be wiped with soap and water or a disinfectant wipe, not an alcohol wipe.
B.Cold formula can cause gastric discomfort or cramping. It's recommended to bring the formula to room temperature before administration to avoid gastric irritation and enhance comfort during feeding.
C.The action of withholding the feeding depends on the institution's protocol and the specific clinical condition of the client. Typically, residuals greater than 200 mL might indicate delayed gastric emptying, but the threshold can vary. A residual volume of 150 mL may not necessarily require withholding the feeding, though it may warrant further assessment.
D.It is standard practice to flush the NG tube with 30 mL of sterile water (or as per facility guidelines) before administering an enteral feeding. This helps ensure the tube is patent, reduces the risk of clogging, and ensures the feeding formula flows smoothly. Flushing before the feeding also helps clear the tube of any residual formula, preventing cross-contamination.
Correct Answer is C
Explanation
A. Dry mucous membranes:
Explanation: Dry mucous membranes are not typically associated with hypoglycemia. Instead, they might be seen in conditions such as dehydration.
B. Fruity breath odor:
Explanation: Fruity breath odor is more commonly associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia, not hypoglycemia.
C. Diaphoresis:
Explanation: Diaphoresis, or excessive sweating, is a common manifestation of hypoglycemia. It results from the activation of the sympathetic nervous system in response to low blood sugar levels.
D. Polyuria:
Explanation: Polyuria, or increased urination, is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia and diabetes.
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