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 ["B","E","C"]
Explanation
Choice A rationale
Hyperresonance is a booming sound elicited during percussion, typically heard over hyperinflated lung tissue, such as in emphysema or pneumothorax. In the abdominal assessment, hyperresonance is generally not an expected finding and may indicate gaseous distension.
Choice B rationale
Flatness is a dull, very soft sound with a short duration, usually heard over dense tissues such as bone or muscle. In the abdomen, flatness is not a typical percussion sound and might be elicited over a large tumor or organomegaly.
Choice C rationale
Dullness is a thud-like sound with a medium intensity and duration, typically heard over solid organs such as the liver, spleen, or a distended bladder. In the abdominal assessment, dullness is an expected finding over these organs.
Choice D rationale
Resonance is a hollow sound of moderate duration and low pitch, typically heard over normal lung tissue. Resonance is not an expected percussion sound in the abdominal assessment; tympany and dullness are the predominant sounds.
Choice E rationale
Tympany is a drum-like sound with high pitch and longer duration, commonly heard over air-filled structures such as the stomach and intestines. Tympany is the predominant percussion sound expected over most of the abdomen due to the presence of gas in the gastrointestinal tract.
Correct Answer is C
Explanation
Choice A rationale
Trouble chewing foods such as meats and raw vegetables is more indicative of mechanical issues with chewing or dental problems rather than dysphagia, which primarily involves difficulty with swallowing. While chewing difficulties can sometimes coexist with dysphagia, the primary characteristic of dysphagia is impaired bolus transport from the mouth to the stomach.
Choice B rationale
Awakenings with a feeling of indigestion suggest issues related to gastric motility or acid reflux, not necessarily dysphagia. Indigestion involves discomfort in the upper abdomen, often related to the digestion of food in the stomach, whereas dysphagia is focused on the process of swallowing.
Choice C rationale
A feeling of choking after swallowing is a classic symptom of dysphagia. It indicates that food or liquid is not passing smoothly from the pharynx to the esophagus and may be entering the airway. This occurs due to impaired coordination or weakness of the muscles involved in swallowing.
Choice D rationale
Frequent burping, or eructation, is typically related to the release of excess gas from the stomach, often due to swallowed air or the breakdown of food. It is not a primary indicator of dysphagia, which is a disorder of the swallowing mechanism.
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