Nokea
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is
- A. prone.
- B. Fowler's.
- C. Sims'.
- D. supine.
Correct Answer: B
Rationale: Fowler's position is the optimal position for a client receiving tube feedings via a gastrostomy tube because it reduces the risk of aspiration. In Fowler's position, the client is sitting up at a 45- to 60-degree angle, which helps prevent the formula from flowing back into the esophagus and causing aspiration pneumonia. Choice A, prone position (lying face down), would not be suitable for administering tube feedings as it increases the risk of aspiration. Sims' position (lying on the left side with the right knee flexed) and supine position (lying flat on the back) are also not ideal for administering tube feedings as they do not provide the same level of protection against aspiration as Fowler's position does.
You may also like to solve these questions
A client with a history of hypertension is prescribed a beta-blocker. Which side effect should the nurse monitor for in this client?
- A. Increased appetite
- B. Dry mouth
- C. Nausea and vomiting
- D. Bradycardia
Correct Answer: D
Rationale: The correct answer is D: Bradycardia. Beta-blockers are known to decrease heart rate, which can lead to bradycardia. This is a common side effect that nurses should monitor for in clients taking beta-blockers. Choices A, B, and C are incorrect because increased appetite, dry mouth, nausea, and vomiting are not typical side effects associated with beta-blockers. Therefore, the nurse should focus on monitoring for bradycardia in this client.
When working with a client who does not speak the same language as the nurse and an interpreter is present, which of the following actions should the nurse take?
- A. Talk directly to the client, instead of the interpreter, when speaking.
- B. Speak loudly to the interpreter.
- C. Use gestures to communicate with the client.
- D. Avoid using an interpreter and rely on family members.
Correct Answer: A
Rationale: When caring for a client who speaks a different language, it is essential to communicate through an interpreter. Talking directly to the client, rather than the interpreter, ensures clear and respectful interaction. Speaking loudly to the interpreter (choice B) is not necessary and may be perceived as disrespectful. Using gestures (choice C) alone may lead to misunderstandings or misinterpretations. Avoiding the use of an interpreter and relying solely on family members (choice D) can compromise the accuracy and confidentiality of the communication.
A parent asks a nurse about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?
- A. A 10-month-old infant can pull up to a standing position.
- B. A 6-month-old infant can walk with assistance.
- C. A 12-month-old infant can jump with both feet.
- D. An 8-month-old infant can crawl on hands and knees.
Correct Answer: A
Rationale: The correct answer is A. By 10 months, infants can typically pull up to a standing position as part of their physical development. Walking with assistance usually begins around 9-12 months, not at 6 months (choice B). Jumping with both feet is a skill that usually develops around 24 months, not at 12 months (choice C). Crawling on hands and knees typically starts around 6-9 months, not at 8 months (choice D). Therefore, the most accurate information to include for an infant's expected physical development at 10 months is the ability to pull up to a standing position.
A nurse receives a prescription for an antibiotic for a client with cellulitis. The nurse checks the client's medical record, discovers the client's allergy to the antibiotic, and calls the provider for a different prescription. Which of the following critical thinking attitudes did the nurse demonstrate?
- A. Fairness
- B. Responsibility
- C. Risk-taking
- D. Creativity
Correct Answer: B
Rationale: The nurse demonstrated responsibility by recognizing the potential harm of administering an antibiotic the client is allergic to and taking the necessary steps to ensure the client's safety. Choice A, 'Fairness,' is not applicable in this scenario as it does not involve treating individuals equitably. Choice C, 'Risk-taking,' is incorrect as the nurse's actions aimed to minimize risks rather than taking them. Choice D, 'Creativity,' is not the best fit as the nurse's actions focused on following established protocols and ensuring patient safety rather than thinking innovatively.
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client fell out of bed. Which of the following statements should the nurse document?
- A. "Client found lying on the floor."
- B. "Client fell out of bed and was found on the floor."
- C. "Client experienced a fall from the bed."
- D. "Client was discovered on the floor following a fall from the bed."
Correct Answer: B
Rationale: The correct answer is B. The documentation should be clear and precise, providing details about the context of the fall. Choice A is vague and does not specify the cause of the client being on the floor. Choice C is less specific and does not directly state that the client fell from the bed. Choice D is wordy and less direct compared to option B, which clearly states that the client fell out of bed and was found on the floor.