An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

Place client on her left side while delivering the bolus.

Ask the client to select a preferred flavor for the bolus.

Elevate head of bed 30 degrees for 1 hour after bolus.

Flush tubing with warm water before and after bolus.

Include amount of feeding when recording fluid Intake.

Answer and Explanation

Correct Answer : C,D,E

A.   Placing the client on her left side is not a standard practice for delivering enteral feedings. Generally, the client should be in a semi-Fowler’s position (head of bed elevated at 30-45 degrees) to minimize the risk of aspiration and aid in digestion.
B.   While asking for a preferred flavor may be appropriate for improving patient comfort and adherence to the feeding regimen, it is not always feasible or necessary, particularly if the client has limited ability to communicate or make choices.
C.   Elevating the head of the bed to 30 degrees for 1 hour after administering a bolus feeding helps to reduce the risk of aspiration and aids in digestion by allowing gravity to assist in moving the feeding into the stomach. This is a standard practice for patients receiving enteral feedings and is important for preventing complications like aspiration pneumonia.
D.   Flushing the tubing with warm water before and after administering the bolus is essential to ensure that the entire amount of feeding is delivered and to prevent clogging of the tube. This practice helps in maintaining tube patency and ensuring that the client receives the full intended dose of nutrition.
E.   It is important to record the amount of enteral feeding as part of the client’s total fluid intake. Accurate documentation helps in monitoring the client’s fluid balance and nutritional intake, which is critical for managing the client’s overall health and adjusting their care plan as needed.

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Correct Answer is C

Explanation

A. Sundowning refers to confusion and agitation that typically occurs in the late afternoon or evening in some individuals with dementia or other cognitive impairments. While important for understanding the client’s cognitive and behavioral patterns, this question is more specific to cognitive or behavioral issues rather than directly assessing functional abilities.
B. Values clarification regarding end-of-life care is crucial, especially for advanced planning and ensuring that care aligns with the client’s preferences. However, this is typically part of a different type of discussion and planning, rather than a general functional assessment.
C. Inquiring about recent falls is a relevant component of a functional assessment. Falls can indicate issues with mobility, balance, strength, or cognitive function, all of which are critical for assessing a client's need for nursing home care. Understanding the frequency and circumstances of falls helps in evaluating the client's overall safety and functional status, which is essential for planning appropriate care.
D. Asking the client to lie still is not typically relevant or necessary for a functional assessment, which
generally involves evaluating the client’s ability to perform activities of daily living (ADLs), mobility, and overall function. A functional assessment often involves observing the client’s movement, activities, and responses, which requires them to be active and engaged rather than lying still.

A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client. B. Listen to the ethics committee discussions and then inform the client what actions should be taken. C. Challenge members of the healthcare team whose opinions differ from the wishes of the client. D. Educate the client about current nursing literature findings related to the client's ethical dilemma.

Correct Answer is A

Explanation

A. Developing self-awareness of personal values is crucial for a nurse acting as an advocate. It ensures
that the nurse’s own beliefs and biases do not interfere with representing the client's wishes and values. This self-awareness helps the nurse advocate effectively for the client’s preferences and decisions without imposing their own personal values.
B. While listening to the ethics committee discussions is important for understanding the context of the ethical dilemma, informing the client about what actions should be taken might not align with the nurse’s role as an advocate. The nurse's role is to represent the client's wishes and interests, not to dictate actions based on the committee’s deliberations.
C. It is important to ensure the client’s wishes are represented, but challenging team members should be done respectfully and constructively. The nurse should focus on presenting the client’s viewpoint clearly and facilitating a discussion that considers the client’s preferences.
D. Educating the client about current literature can be helpful, but it is not the primary responsibility of the nurse in the role of an advocate at an ethics committee meeting. The nurse’s primary role is to
represent the client’s wishes and ensure their voice is heard in the ethical decision-making process.

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An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Correct Answer is C

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

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