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 A

Explanation

A. Encouraging the spouse to share their feelings is the most appropriate initial action. It provides an opportunity for the spouse to express their emotions and begin processing their grief. This approach validates the spouse’s feelings, offers emotional support, and establishes a supportive environment where the spouse can feel heard and understood.
B. Offering reassurance that the spouse is not alone can be comforting, but it may not fully address the immediate emotional needs of the spouse. It is important to first allow the spouse to express their feelings and then provide reassurance as part of the ongoing support.
C. Discussing alternative treatment options may be premature and could be perceived as dismissive of the spouse’s immediate emotional response. At this moment, the spouse is focused on the emotional impact of the terminal diagnosis rather than treatment options.
D. While offering hope can be part of supportive care, this approach might unintentionally minimize the spouse’s current feelings of loss and grief. It can also come across as dismissive of the immediate emotional impact of the diagnosis.

A. Assess the client's brain stem reflexes. B. Perform pupillary response assessment. C. Assess the client's blood pressure. D. Offer the client to void before getting out of bed.

Correct Answer is C

Explanation

A. While assessing brain stem reflexes can provide valuable information about the neurological status of the client, it is not the immediate priority when preparing to move a client from bed to a chair. Brain stem reflexes are more relevant for assessing overall neurological function and response to stimuli, but they do not directly inform the safety and readiness of the client for physical activity.
B. Assessing the pupillary response is important for evaluating neurological function and consciousness levels. However, it is not directly related to assessing the client’s readiness to be moved from bed to a chair. Pupillary response does not provide specific information about the client’s hemodynamic stability or immediate readiness for physical activity.
C. Assessing the client’s blood pressure is crucial, especially after a stroke, as the client may be at risk for orthostatic hypotension (a sudden drop in blood pressure when standing up). Checking blood pressure helps ensure that the client is hemodynamically stable and can tolerate the change in position without risking dizziness, fainting, or other complications.
D. Offering the client the opportunity to void before getting out of bed is a practical measure to ensure comfort and avoid accidents. It helps prevent the need for the client to seek the bathroom immediately after being moved to the chair, which could be disorienting or potentially hazardous.

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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

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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