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.
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Related Questions
Correct Answer is B
Explanation
A. Using an indwelling urinary catheter should be avoided unless absolutely necessary due to the associated risks of infection and other complications. It's not the first-line intervention for managing urinary incontinence.
B. Frequent toileting, also known as scheduled toileting or prompted voiding, is an effective intervention for managing urinary incontinence in older adults with dementia. It helps prevent accidents by ensuring the client has regular opportunities to use the
bathroom.
C. Reminding the client to tell the nurse when they need to urinate can be helpful, but it may not be sufficient on its own, especially for individuals with dementia who may have difficulty recognizing or communicating their needs.
D. Using adult diapers should be considered a last resort, as it does not address the underlying issue and may not promote the client's independence or dignity.
Correct Answer is A
Explanation
A. Having the client wear a mask is the most appropriate precaution for safely
transporting a client with active pulmonary tuberculosis (TB) who requires airborne precautions. This helps contain potentially infectious respiratory droplets.
B. Asking the x-ray technician to come to the client's room to obtain a portable X-ray is a reasonable option, but it may not always be feasible depending on the facility's resources and policies.
C. Notifying the x-ray department that the client requires airborne precautions is an important step, but it is not sufficient on its own. The client should also wear a mask during transport.
D. Wearing a filtration mask and gloves during transport is not enough. The nurse should also ensure that the client is wearing a mask to contain respiratory secretions.
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