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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Goggles are not typically necessary for droplet precautions unless there is a risk of splashing or spraying of respiratory secretions.
B. A gown is not specifically required for droplet precautions. However, if there is a risk of contamination from respiratory secretions, a gown may be used in addition to other precautions.
C. When setting up a meal tray for a client requiring droplet precautions, the nurse should wear a mask to protect against potential exposure to respiratory droplets.
D. Gloves are not typically required for setting up a meal tray under droplet precautions, as there is no direct contact with potentially contaminated surfaces.
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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