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

Explanation

A. Apply Neosporin to avoid infection:
This choice suggests applying Neosporin to the surgical site. However, the immediate postoperative care for cleft lip surgery often involves keeping the incision site covered with sterile dressings. Topical antibiotics may be prescribed by the healthcare provider if deemed necessary, but it's not a routine application without specific instructions.

B. Apply elbow immobilizers when not being held:
This choice implies using elbow immobilizers for the child. However, elbow immobilizers are not a standard intervention for cleft lip surgery. The focus is usually on keeping the surgical site clean and preventing complications like infection.

C. Suction secretions away from the suture line:
This is the recommended choice. Suctioning helps maintain a clear airway and prevents secretions from affecting the surgical site. It's a crucial step in the immediate postoperative period.

D. Feed increased amounts of formula to prevent weight loss:
While feeding is an essential aspect of care, especially for nutritional support, the immediate concern in the first few days after cleft lip surgery is often related to maintaining a patent airway and preventing infection. Feeding interventions might be guided by the healthcare provider's recommendations, but it's not the primary focus in the initial postoperative period.

A. Height of the IV pole B. IV insertion site C. Manifestations of hypoglycemia D. The client's oral intake

Correct Answer is C

Explanation

A. Height of the IV pole:
Explanation: The height of the IV pole is important for controlling the rate of the TPN infusion. Adjusting the height can regulate the flow rate.

B. IV insertion site:
Explanation: Monitoring the IV insertion site is crucial to assess for signs of infection, inflammation, or infiltration, which can compromise the effectiveness of TPN.

C. Manifestations of hypoglycemia:
Explanation: TPN often contains glucose, and monitoring for signs of hypoglycemia is important, as abrupt cessation of TPN can lead to low blood glucose levels.

D. The client's oral intake:
Explanation: Since the client is receiving TPN, their oral intake is not the primary source of nutrition. TPN provides essential nutrients intravenously.

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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

During the first few days after surgery for cleft lip, which intervention should the nurse implement?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?

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A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting?

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data represents an adverse outcome (side effect) of this infusion?

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?