A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Observe the client's respiratory status.

Monitor intake and output every 8 hr.

Elevate the head of the client's bed 30° to 45°.

Check residual volume every 4 to 6 hr.

Answer and Explanation

The Correct Answer is C

A. Observing the client's respiratory status is also important, but it is an ongoing assessment rather than an immediate action.

B. Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.

C. This is crucial to prevent aspiration, which can occur if the feeding formula enters the lungs, leading to pneumonia or other serious complications. Elevating the head of the bed helps keep the esophagus above the stomach, reducing the risk of aspiration.

D. Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.

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Correct Answer is A

Explanation

A. This statement is incorrect. While HIPAA allows for certain disclosures to family members, it is important to follow specific guidelines and obtain appropriate consent or authorization from the client when sharing their health information. There are also circumstances where a client may request that information be withheld from certain family members.
B. This statement is correct. HIPAA is a federal law that establishes privacy standards for protected health information.
C. This statement is correct. A client's address is considered personally identifiable information under HIPAA.
D. The statement appears to be cut off. However, it is important to note that HIPAA does indeed establish regulations for protecting individually identifiable health information in various forms, including verbal, electronic, and written.

A. More difficulty seeing due to a greater sensitivity to glare B. Dehydration of intervertebral discs C. Decreased systolic blood pressure D. Decreased cough reflex E. Decreased bladder capacity

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

Explanation

A. More difficulty seeing due to a greater sensitivity to glare is a common age-related change in vision.

B. Dehydration of intervertebral discs can occur with aging, leading to decreased flexibility and potentially contributing to back pain.

C. While systolic blood pressure may increase with age, decreased systolic blood pressure is not a typical age-related change.

D. Decreased cough reflex is an expected change, which can lead to an increased risk of respiratory infections in older adults.

E. Decreased bladder capacity is an expected age-related change due to changes in the bladder muscles and elasticity of the tissues. This can contribute to increased frequency of urination in older adults.

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A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Nursing Test Bank

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