A tracheostomy patient is experiencing regurgitation of tube feeding formula. What should be the nurse's first priority?
Placing the patient in prone position to improve draining from mouth
Checking to make sure the tracheostomy cuff is inflated during tube feedings
Placing the patient in the right lateral decubitus position to promote gastric emptying
Discussing the use of metoclopramide to facilitate gastric motility with the practitioner
The Correct Answer is B
A. The prone position is not recommended for managing tube feeding regurgitation, as it could lead to aspiration into the lungs.
B. The first priority is to ensure that the tracheostomy cuff is inflated during tube feedings to prevent aspiration and to ensure that the feeding is directed into the stomach and not into the airway.
C. The lateral decubitus position can help with gastric emptying, but the priority is to ensure proper cuff inflation to prevent aspiration.
D. While metoclopramide may help with gastric motility, the immediate concern is managing the risk of aspiration, which requires confirming cuff inflation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Overlooking the patient's need to talk is incorrect because ignoring their emotional distress may increase feelings of isolation and hopelessness.
B. Discontinuing psychotropic medications is incorrect as these medications may be essential in stabilizing mood and preventing further self-harm.
C. Validating the patient's worth and self-esteem is correct as it helps promote a sense of value, belonging, and hope, which are crucial in suicide prevention and recovery.
D. Limiting interaction with the patient is incorrect because social isolation can worsen depression and increase the risk of further self-harm.
Correct Answer is D
Explanation
A. The Code of Ethics for Nurses offers broad ethical guidelines, but it does not provide specific clinical practice guidelines.
B. The Code does touch on social justice issues, but it is not primarily focused on critiquing societal oppression or domination.
C. While the Code supports good care, it is more about establishing ethical standards rather than providing direct care guidelines.
D. The Code expresses nursing's commitment to society, outlining the profession's ethical standards and obligations toward patients and society as a whole.
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