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

High-fiber cereals are generally avoided on a soft diet because their roughage content can be difficult to digest and may cause gastrointestinal discomfort. A soft diet aims to minimize digestive work.

Choice B rationale

Fruit with the skin contains a significant amount of fiber, which is not appropriate for a soft diet. The skin is often the toughest part of the fruit and requires more digestion.

Choice C rationale

Raw vegetables are typically high in fiber and have a firm texture, making them difficult to chew and digest for individuals on a soft diet. Cooking vegetables softens their fibers.

Choice D rationale

Ground beef, when cooked thoroughly and is tender, is a suitable protein source for a soft diet. The grinding process breaks down the muscle fibers, making it easier to chew and digest compared to whole cuts of meat.

A. Side-lying with head of bed (HOB) at 30 degrees. B. In the tripod position; leaning over the over the bed table on the left side with chin-to-chest. C. Sitting the patient in an upright position. D. Sitting the patient in an upright position and hyperextending the patient's head.

Correct Answer is C

Explanation

Choice A rationale

The side-lying position with the head of bed at 30 degrees does not optimally align the nasal passages with the esophagus, increasing the risk of the NGT entering the trachea. Proper alignment facilitates easier and safer insertion into the stomach.

Choice B rationale

The tripod position is typically used for patients experiencing respiratory distress to maximize lung expansion. It does not provide the necessary head and neck alignment for safe nasogastric tube insertion.

Choice C rationale

Sitting the patient in an upright position, ideally between 45 to 90 degrees, uses gravity to aid the passage of the NGT down the esophagus. This position also allows the patient to cough effectively if the tube inadvertently enters the trachea.

Choice D rationale

Hyperextending the patient's head during NGT insertion can close off the esophagus and open the trachea, significantly increasing the risk of misplacement of the tube into the respiratory tract. The neck should be flexed forward with the chin to the chest during insertion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with teaching a client who is on a soft diet.Which of the following foods should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse positions a patient for the insertion of a nasogastric (NGT) tube by:

Correct Answer is C

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?