A newly hired nurse is attending an in-service about fire safety. Which of the following actions should the nurse take first in the event of a fire?

A. Laboratory electrolyte levels: The client’s potassium (3.7 mEq/L) and sodium (137 mEq/L) are within expected reference ranges. These values do not indicate electrolyte imbalance or metabolic instability that would require holding the feeding. Electrolyte disturbances can occur with enteral nutrition, but current results do not support discontinuation.

B. Oxygen saturation: An oxygen saturation of 96% on room air reflects adequate oxygenation and does not indicate aspiration or respiratory compromise. If aspiration from tube feeding had occurred, decreased oxygen saturation or respiratory distress might be present. Current findings do not justify holding the feeding based on oxygenation status.

C. Abdominal findings: A distended, firm, and tense abdomen suggests possible feeding intolerance, delayed gastric emptying, or bowel obstruction. These findings increase the risk for regurgitation and aspiration if feeding continues. Abdominal distention in the presence of enteral nutrition warrants holding the feeding and notifying the provider for further evaluation.

D. Blood glucose: A blood glucose of 152 mg/dL falls within the prescribed correction scale requiring 2 units of regular insulin. Mild hyperglycemia is common with enteral feedings and is addressed with sliding-scale insulin as ordered. This value alone does not require stopping the feeding.

E. Gastric residual: A gastric residual of 90 mL may indicate delayed gastric emptying, particularly when accompanied by abdominal distention. Elevated residual volumes increase the risk of aspiration if feeding continues. Clinical context, including abdominal findings, supports holding the feeding and notifying the provider.

F. pH of gastric contents: A pH of 6.4 is higher than expected for gastric contents, which are typically acidic (pH ≤5). An elevated pH raises concern for possible tube displacement into the respiratory tract or small intestine. This finding requires further verification of placement before continuing feedings.

A. Wearing sterile gloves when collecting a urine specimen from an indwelling urinary catheter: Sterile gloves are not required for routine urine specimen collection from an indwelling catheter unless the procedure involves breaking the closed system for insertion or manipulation. Using sterile gloves unnecessarily increases supply costs without improving safety.

B. Donning an N95 mask before caring for a client who is on contact precautions: Contact precautions require gloves and a gown, not an N95 respirator. Using an N95 inappropriately consumes a more expensive resource without providing additional protection, which is not cost-effective. Appropriate PPE selection should be based on transmission precautions.

C. Returning unopened supplies to the storage room: Returning unopened supplies for future use prevents unnecessary waste and reduces institutional costs. Supplies that remain sterile and intact can be reused for other clients, demonstrating effective resource management while maintaining safety standards.

D. Replacing a continuous feeding administration set every 8 hr: Standard guidelines recommend replacing continuous enteral feeding sets every 24 hours to prevent infection, unless otherwise indicated. Replacing them every 8 hours unnecessarily increases supply use and cost without additional safety benefit, making it a less cost-effective practice.