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 C
Explanation
A. Hypertension:
Hypovolemia is characterized by a decrease in blood volume. This reduction in blood volume usually leads to decreased blood pressure, not hypertension.
B. Peripheral edema:
Edema is more commonly associated with hypervolemia (excess fluid volume) rather than hypovolemia. In hypovolemia, the body is experiencing a deficit of fluids, and edema is not a typical manifestation.
C. Oliguria:
This is the correct answer. Oliguria, or reduced urine output, is a common finding in hypovolemia. When the body is low on fluids, the kidneys try to conserve water by decreasing urine production.
D. Bradycardia:
Hypovolemia often leads to tachycardia (an increased heart rate) as the body attempts to compensate for the decreased blood volume by pumping the existing blood more quickly. Bradycardia is not a typical finding in hypovolemia.
Correct Answer is B
Explanation
A. Proliferation Phase:
Explanation: This phase involves the formation of new tissue to fill the wound space. It includes granulation tissue formation and wound contraction.
B. Inflammation Phase:
Explanation: This is the initial phase characterized by hemostasis and inflammation, aimed at stopping bleeding and preventing infection. Blood vessels constrict, platelets aggregate, and inflammatory cells arrive at the wound site.
C. Maturation Phase:
Explanation: Also known as the remodeling phase, it involves the remodeling and realignment of collagen fibers and the strengthening of scar tissue.
D. Remodeling Phase:
Explanation: Remodeling and maturation are often considered together as the final stage of wound healing, where collagen fibers reorganize and gain strength.
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