A nurse is caring for a patient who is receiving enteral feeding. Which of the following interventions is the highest priority when the nurse suspects aspiration of the feeding?
Auscultate breath sounds
Stop the feedings
Obtain a chest x-ray
Initiate antibiotic therapy
The Correct Answer is B
a) Auscultate breath sounds: While auscultating breath sounds may reveal signs of aspiration (e.g., crackles), stopping the feedings is the immediate priority to prevent further aspiration and reduce the risk of complications like aspiration pneumonia.
b) Stop the feedings: The highest priority is to stop the enteral feedings immediately to prevent further aspiration and potential damage to the lungs, followed by further assessments.
c) Obtain a chest x-ray: A chest x-ray can confirm the presence of aspiration or pneumonia but is not the immediate priority. Stopping the feedings is more urgent.
d) Initiate antibiotic therapy: Antibiotics may be needed if aspiration pneumonia is suspected, but they should not be the first intervention. Stopping the feedings and assessing the patient should be done first.
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Related Questions
Correct Answer is D
Explanation
a) Kinking the catheter tubing to obtain a urine specimen: Kinking the catheter tubing can cause backflow of urine, increasing the risk of infection, but it is not as significant a risk factor as improper drainage bag positioning.
b) Emptying the drainage bag every 8 hours or when half full: Properly emptying the drainage bag regularly reduces the risk of infection, as it prevents overfilling and backflow. This practice is usually part of proper care.
c) Failing to secure the catheter tubing to the patient's thigh: Securing the tubing to the thigh is important for preventing pulling or tension, but it’s not as significant in terms of infection risk as the positioning of the drainage bag.
d) Placing the drainage bag on the side rail of the patient's bed: This significantly increases the risk of urinary tract infections (UTIs) as it can cause the urine to flow back into the bladder, a condition called "reflux." The drainage bag should always be kept below the level of the bladder.
Correct Answer is A
Explanation
a) Fecal Impaction: Seepage or leaking of liquid stool often occurs when a patient has a fecal impaction. The liquid stool may leak around the solid mass of stool that is impacted in the colon.
b) Urinary Incontinence: Urinary incontinence refers to the involuntary loss of urine, not stool.
c) Bowel and Bladder training program: While bowel and bladder training programs may be helpful for managing incontinence, they are not the immediate solution for fecal impaction.
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