A nurse is developing a care plan for a patient with a decreased level of consciousness who is receiving continuous enteral feedings through a gastrostomy tube due to an inability to swallow.
What should be the nurse’s priority action?
Observe the patient’s respiratory status.
Elevate the head of the patient’s bed 30° to 45°.
Monitor intake and output every 8 hours.
Check residual volume every 4 to 6 hours.
The Correct Answer is B
Choice A rationale
While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.
Choice B rationale
Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.
Choice C rationale
Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.
Choice D rationale
Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A black pressure ulcer indicates necrotic tissue, which often requires surgical debridement.
Choice B rationale
Increased drainage from the wound is not typically associated with a black pressure ulcer.
Choice C rationale
While documenting the wound status daily is part of wound care, it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
Choice D rationale
Increased monitoring of the wound condition is part of wound care, but it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
Correct Answer is D
Explanation
Choice A rationale
Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.
Choice B rationale
A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.
Choice C rationale
Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.
Choice D rationale
In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.
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