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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

The correct answer is choicea. Increase daily caloric intake by 300 to 400 calories,b. Consume folic acid supplements daily, andd. Take daily iron and calcium supplements.

Choice A rationale:

Pregnant teenagers need to increase their daily caloric intake by 300 to 400 calories to support the growth and development of the fetus.

Choice B rationale:

Folic acid is crucial for preventing neural tube defects in the developing fetus.Daily supplementation is recommended.

Choice C rationale:

Pregnant teenagers need to increase their protein intake to support fetal growth and maternal health.Maintaining current protein intake is not sufficient.

Choice D rationale:

Iron and calcium are essential for the development of the fetus and the health of the mother.Daily supplementation helps prevent deficiencies.

Choice E rationale:

Limiting weight gain to no more than 15 pounds is not recommended.Healthy weight gain during pregnancy varies but is generally higher than 15 pounds to support fetal development.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.

The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What should a nurse include in a nutrition class for pregnant teenagers? Choose all that apply.

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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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?