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
A. Assist the client to low Fowler's position:
Placing the client in a semi-upright or low Fowler's position during and after the feeding helps prevent aspiration and facilitates digestion. This position reduces the risk of regurgitation and reflux.
B. Warm the feeding solution to body temperature:
Ensuring the feeding solution is at room temperature or slightly warmer can enhance the client's comfort and reduce the risk of cramping or discomfort caused by cold fluids.
C. Discard any residual gastric contents:
Before initiating a new feeding, it's essential to check and discard any residual gastric contents from the previous feeding to prevent contamination, ensure accurate measurement, and minimize the risk of bacterial growth.
D. Test the pH of gastric aspirate:
Checking the pH of gastric aspirate is an important step to confirm the proper placement of the NG tube in the stomach. Gastric pH is typically acidic (pH less than 5), indicating the correct placement of the tube in the stomach rather than the respiratory tract, where the pH is higher (more alkaline).
Correct Answer is D
Explanation
A. "My appetite will be decreased."
Explanation: Hyperglycemia is often associated with increased appetite rather than decreased appetite.
B. "I might experience blurry vision at times."
Explanation: This is correct. Blurry vision can be a symptom of hyperglycemia due to changes in the fluid levels in the eye caused by high blood sugar.
C. "My breath may have a fruity odor."
Explanation: Fruity breath odor is associated with diabetic ketoacidosis (DKA), which is a severe complication of diabetes. It occurs due to the production of ketones during uncontrolled diabetes, leading to this distinct odor. While it's related to high blood sugar, it's more specifically linked to DKA.
D. "I will be more thirsty than usual."
Explanation: Increased thirst is a classic symptom of hyperglycemia. When blood sugar levels are high, the body tries to flush out the excess sugar through increased urination, leading to dehydration and subsequently increased thirst.
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