A nurse is about to administer a bolus enteral feeding to a client who is on bedrest. How does the nurse position the client during the feeding?
On left side, with the knees bent
With the head of the bed elevated 30-45 degrees
On the right side, with a pillow behind the back
With the head of the bed elevated 15 degree
The Correct Answer is B
B. Elevating the head of the bed to 30-45 degrees is the recommended position for administering enteral feeding to reduce the risk of aspiration. This semi-upright position helps promote gastric emptying and reduces the likelihood of reflux or regurgitation of the feed into the lungs. It also allows for better tolerance of the feeding and minimizes the risk of complications.
A. Positioning the client on the left side with the knees bent is not typically recommended for enteral feeding. This position may increase the risk of aspiration, especially if the client has impaired swallowing or if there are issues with gastric emptying. It may also not be the most comfortable or practical position for administering enteral feeding.
C. Positioning the client on the right side with a pillow behind the back is not a standard practice for administering enteral feeding. This position may not provide optimal access for administering the feed, and it does not offer the benefits of head elevation to reduce the risk of aspiration.
D. Elevating the head of the bed to only 15 degrees may not provide sufficient upright positioning to reduce the risk of aspiration during enteral feeding. While it is better than lying completely flat, a higher degree of elevation (30-45 degrees) is generally recommended for optimal safety and effectiveness of enteral feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. A healthy stoma should appear moist and shiny, indicating adequate blood supply and hydration of the tissue. Dryness or dullness of the stoma may indicate poor blood flow or dehydration and should be further evaluated.
B. A healthy stoma typically appears deep pink to red in color, indicating good tissue perfusion. Pallor or cyanosis of the stoma may indicate inadequate blood supply and should be assessed promptly.
C. The skin around the stoma, known as the peristomal skin, should be intact, without signs of irritation, redness, or tenderness. Irritation or breakdown of the peristomal skin can occur due to leakage of stool or irritation from ostomy appliances and should be addressed promptly to prevent skin complications.
D. A flat abdomen suggests normal abdominal contour without distention or bulging. Distention or bulging of the abdomen may indicate underlying issues such as bowel obstruction, gas accumulation, or fluid retention and should be assessed further.
E. Bowel sounds are indicative of gastrointestinal motility and function. Normal bowel sounds are present and audible in healthy individuals and are characterized by 8 to 10 clicks or gurgles per minute. Absence or abnormal bowel sounds may indicate bowel obstruction, ileus, or other gastrointestinal disorders and should be assessed further.
Correct Answer is ["A","D"]
Explanation
A. The renal arteries are not typically located in the right upper quadrant. This area primarily contains the liver, gallbladder, and portions of the small intestine and large intestine. Therefore, RUQ is not associated with the location of the renal arteries.
D. LUQ (Left Upper Quadrant): The renal arteries are not typically located in the left upper quadrant. This area primarily contains the spleen, stomach, pancreas, and portions of the small intestine and large intestine. Therefore, LUQ is not associated with the location of the renal arteries.
B. Hypogastric: The hypogastric region, also known as the pubic region or lower abdominal region, is located below the umbilical region (lower middle abdomen). The renal arteries are not typically located in the hypogastric region. This area primarily contains structures such as the bladder, uterus (in females), and reproductive organs. Therefore, hypogastric is not associated with the location of the renal arteries.
C. LLQ (Left Lower Quadrant): The renal arteries are not typically located in the left lower quadrant. This area primarily contains the descending colon, sigmoid colon, and portions of the small intestine. Therefore, LLQ is not associated with the location of the renal arteries.
E. RLQ (Right Lower Quadrant): The renal arteries are not typically located in the right lower quadrant. This area primarily contains the appendix, cecum, ascending colon, and portions of the small intestine. Therefore, RLQ is not associated with the location of the renal arteries.
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