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 D
Explanation
Choice A rationale
Measuring the bladder before the patient voids would not provide an accurate measurement of postvoid residual, which is the amount of urine left in the bladder after voiding.
Choice B rationale
The position of the head of the bed does not directly impact the measurement of postvoid residual. However, the patient should be in a comfortable position during the procedure.
Choice C rationale
Similar to Choice B, the position of the head of the bed does not directly impact the measurement of postvoid residual.
Choice D rationale
Measuring the bladder within 15 minutes after the patient voids allows for an accurate measurement of postvoid residual, which can help assess bladder function.
Correct Answer is D
Explanation
Choice A rationale
Fresh vegetables are generally not considered bladder irritants. They are part of a healthy diet and do not typically cause bladder irritation.
Choice B rationale
Red meat is not typically associated with bladder irritation. While some individuals may have specific dietary sensitivities, red meat is not commonly known to irritate the bladder.
Choice C rationale
Dairy products are not typically associated with bladder irritation. However, some individuals may have lactose intolerance or other specific sensitivities to dairy products.
Choice D rationale
Caffeinated beverages can irritate the bladder. Caffeine is a diuretic, which means it can increase urine production and potentially lead to bladder irritation.
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