A nurse is teaching the client's spouse about positioning the client to administer his enteral feedings.
Which of the following statements indicates the spouse needs further teaching?

"I will check his gastric residual volume before feeding and giving him his meds.”.

"I will turn him on his left side after meds and feeding.”.

"I will elevate the head of the bed 30-45 degrees when giving his feedings.”.

"I will leave him in his position of comfort while feeding him.”.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Checking gastric residual volume is essential before administering enteral feedings and medications to assess for delayed gastric emptying, which could increase the risk of aspiration. A high residual volume (typically >500 mL or >250 mL on two consecutive checks) may indicate intolerance to the feeding.

Choice B rationale

Turning the client on their left side after administering enteral feedings and medications is not the recommended position. The right lateral decubitus position is preferred as it promotes gastric emptying by allowing gravity to assist the flow of the feeding into the small intestine.

Choice C rationale

Elevating the head of the bed to a 30-45 degree angle during and for at least 30-60 minutes after enteral feedings significantly reduces the risk of aspiration pneumonia. This position utilizes gravity to help keep the feeding within the stomach and prevent reflux into the esophagus and airway.

Choice D rationale

Leaving the client in their position of comfort while feeding them is incorrect. Maintaining an elevated head of bed position (30-45 degrees) is crucial during and after feeding to prevent aspiration, regardless of the client's perceived comfort. A flat or semi-recumbent position increases the risk of regurgitation and subsequent aspiration into the lungs.

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Correct Answer is D

Explanation

Choice A rationale

While prostate enlargement is common in older men, it is not typically directly associated with bilateral gynecomastia. Gynecomastia primarily involves breast tissue enlargement due to hormonal imbalances, not glandular changes related to the prostate. Recommending prostate screening solely based on gynecomastia is not the most direct or scientifically sound approach.

Choice B rationale

Acknowledging gynecomastia as benign breast enlargement without further investigation might be premature. While some cases in older men are benign and related to aging, it can also be a symptom of underlying medical conditions or medication side effects that require evaluation. Dismissing it without investigation could miss a treatable cause.

Choice C rationale

A mammogram is a screening tool for breast cancer, which is rare in men but possible. However, gynecomastia is characterized by benign glandular tissue proliferation, distinct from the tissue changes typically associated with male breast cancer. While a physician might order one to rule out malignancy, it's not the initial recommended action based solely on the finding of bilateral gynecomastia.

Choice D rationale

Gynecomastia in men can result from various hormonal changes, including a decrease in testosterone levels relative to estrogen, or an increase in estrogen production. Certain medical conditions and medications can also disrupt hormonal balance. Recommending a physician visit to investigate potential underlying causes of hormonal changes is the most appropriate initial action to determine the etiology of the gynecomastia and guide further management.

Correct Answer is ["1"]

Explanation

The correct answer is 1 mL.

Step 1 is: Examine the medication label to determine the concentration of epoetin. The label indicates a concentration of 30,000 units per 1 mL.

Step 2 is: Set up the calculation to find the volume needed by dividing the ordered dose by the concentration: 30,000 units ÷ (30,000 units/mL).

Step 3 is: Perform the division: 30,000 ÷ 30,000 = 1.

Step 4 is: The units cancel out, leaving the volume in milliliters: 1 mL. Final answer is 1 mL.

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A nurse is teaching the client's spouse about positioning the client to administer his enteral feedings.Which of the following statements indicates the spouse needs further teaching?

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Naxlex Comprehensive Predictor Exams

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia.Which of the following describes the nurse's best course of action?

Correct Answer is D

Explanation

The physician orders epoetin 30,000 units subcutaneously for anemia. The medication is per the provided label on the supplemental exam sheet. How many milliliters will the nurse administer? SEE LABEL #1 for drug availability.

Correct Answer is ["1"]

Explanation

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A nurse is teaching the client's spouse about positioning the client to administer his enteral feedings.
Which of the following statements indicates the spouse needs further teaching?