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.”.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1: The physician ordered 10 mg per dose.
Step 2: The available tablet strength is 5 mg per tablet.
Step 3: To find the number of tablets per dose, divide the ordered dose by the tablet strength: 10 mg ÷ 5 mg/tablet = 2 tablets.
Step 4: The nurse will administer 2 tablets per dose.
Final answer: 2 tablets.
Correct Answer is B
Explanation
Choice A rationale
Palpating the tender area first can cause increased pain and muscle guarding, potentially interfering with the subsequent auscultation of bowel sounds. It is important to auscultate before palpation to avoid altering the natural bowel sounds.
Choice B rationale
Examining the tender area last minimizes the client's discomfort and reduces the likelihood of muscle guarding affecting the assessment of other abdominal areas. This systematic approach allows for a more accurate evaluation of non-tender regions before focusing on the area of complaint.
Choice C rationale
Examining the tender area first will likely cause the patient increased discomfort, leading to muscle guarding that can make it difficult to accurately assess other areas of the abdomen. This approach can also make the patient apprehensive and less cooperative for the remainder of the examination.
Choice D rationale
Avoiding palpation of the tender area altogether would result in an incomplete assessment. Palpation is crucial for evaluating tenderness, masses, and organomegaly in the area of the patient's pain. Modifying the order of assessment is preferred over complete avoidance.
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