A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Decrease the rate of the feeding by half.

Observe for an allergic reaction to the formula.

Hang a new bag of the enteral formula.

Stop the tube feeding and assess the client.

Answer and Explanation

The Correct Answer is D

A.   Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B.   While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C.   Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D.   Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

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Correct Answer is D

Explanation

A. While determining if medications can be given in generic form can be a cost-effective measure and might be beneficial for the client, it is not the most urgent action to take during the admission process. The primary focus should be on ensuring that the medications are correct, safe, and appropriate for the client’s current condition and needs.
B. Client education about the desired effects of medications is important for ensuring the client understands their treatment and can identify any side effects or issues. However, this is typically done after ensuring that the medication list is accurate and reconciled. Teaching should be part of a comprehensive plan once the medication list and dosages are confirmed.
C. Reconciliation of prescribed medication dosages with recommended dosage ranges is important for ensuring the client receives appropriate and safe dosages. However, this action is part of a broader process of medication reconciliation, which involves verifying and comparing the current list of medications against previous records and established guidelines.
D. Comparing admission prescriptions with the list of medications previously taken by the client is a crucial first step in the medication reconciliation process. This action ensures that there is no duplication, omission, or incorrect change in the medication regimen. It helps prevent potential medication errors and ensures continuity of care.

A. Before changing assignments, determine which staff members have fitted particulate filter masks. B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client. C. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. D. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.

Correct Answer is D

Explanation

A. This action involves assessing which staff members are appropriately equipped to handle the situation. While it is useful to know which staff are fitted with particulate filter masks, this step does not directly address the UAP’s immediate concern or resolve the issue with the current assignment.
B. Pertussis (whooping cough) is a disease that requires droplet precautions, which generally means using a standard surgical mask rather than a particulate filter mask. However, it’s crucial to ensure that the UAP is aware of and follows the correct infection control measures.
C. Pertussis requires droplet precautions, which usually involve wearing a standard surgical mask, not a particulate filter mask (N95). Fitting for an N95 mask is generally reserved for airborne precautions.
D. This action addresses the immediate need by allowing the UAP to perform tasks that do not involve close personal care (such as taking vital signs) with a standard face mask, which is appropriate for droplet precautions. It also ensures that the UAP receives proper fitting for a particulate filter mask if needed for other tasks or future assignments.

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A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Nursing Test Bank

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Explanation

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Explanation

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