A nurse is teaching a client and his son about how to position when administering enteral feedings at home. Which of the following statements by the client indicates an understanding of the teaching?

"I will turn him every 2 hours during the feeding."

"I will have him sit in his chair during the feeding."

"I will elevate the head of the bed 10 degrees during the feeding."

"I will allow him to be in the position where he is most comfortable during the feeding."

Answer and Explanation

The Correct Answer is B

A. "I will turn him every 2 hours during the feeding.": Turning during feeding is unnecessary and could increase the risk of aspiration.

B. "I will have him sit in his chair during the feeding.": A sitting or high Fowler's position reduces the risk of aspiration during enteral feedings.

C. "I will elevate the head of the bed 10 degrees during the feeding.": The head of the bed should be elevated at least 30-45 degrees to prevent aspiration.

D. "I will allow him to be in the position where he is most comfortable during the feeding.": Proper positioning is essential for safety and cannot be based solely on comfort.

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Correct Answer is D

Explanation

A. Place the client in low Fowler's position: A low Fowler's position increases the risk of aspiration in clients with myasthenia gravis due to weakened swallowing muscles. High Fowler's position is preferred.

B. Have the client empty their bladder: Emptying the bladder is unrelated to safe administration of PO medications.

C. Put up the side rails on the client's bed: While safety is important, this does not directly address swallowing or medication administration.

D. Ask the client to take a few sips of water: This assesses the client's ability to swallow safely, which is crucial for preventing aspiration in clients with myasthenia gravis.

A. Adjust the prescribed weights every shift. B. Position weights against the foot of the bed. C. Monitor peripheral pulses in the affected extremity. D. Examine the skin under the traction splint. E. Assess the temperature of the affected extremity.

Correct Answer is ["C","D","E"]

Explanation

A. Adjust the prescribed weights every shift: Traction weights should never be adjusted without a provider's order, as it can disrupt alignment.

B. Position weights against the foot of the bed: Weights should hang freely to maintain traction effectiveness.

C. Monitor peripheral pulses in the affected extremity: Ensuring adequate circulation is critical to prevent complications like compartment syndrome.

D. Examine the skin under the traction splint: Regular skin checks prevent pressure injuries and breakdown from the traction device.

E. Assess the temperature of the affected extremity: Temperature changes may indicate circulatory compromise or infection.

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A nurse is teaching a client and his son about how to position when administering enteral feedings at home. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication?

Correct Answer is D

Explanation

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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