After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

Choice A reason: Before initiating tube feeding, it is crucial to ensure that the gastrointestinal system is functioning. The presence of bowel sounds indicates peristalsis, which is necessary for the digestion and absorption of the feeding.

Choice B reason: While measuring the client's total body weight is important for overall assessment and monitoring of nutritional status, it is not the most critical assessment before starting tube feeding.

Choice C reason: Evaluating the client's ability to swallow is not relevant in this scenario since the client will be receiving nutrition through a feeding tube due to malnutrition and dehydration.

Choice D reason: Observing for signs of fluid volume deficit is important, but the immediate concern before starting tube feeding is to confirm gastrointestinal activity through the presence of bowel sounds.

Choice A reason:

There is no mention of an open wound that requires cleansing and dressing, so this action is not applicable based on the provided patient data.

Choice B reason:

The patient has blanchable redness on both heels and the coccyx, which are signs of pressure injury risk. Ofloading these areas is essential to prevent the development of pressure ulcers.

Choice C reason:

There is no indication of elder abuse in the provided scenario, so contacting adult protective services would not be appropriate.

Choice D reason:

Given the patient's difficulty with mobility and the reported occasional accidents, a bowel training program could help manage his bowel incontinence and improve his quality of life.

Choice E reason:

An enema is not indicated as there is no evidence of constipation or bowel obstruction in the patient's history or nurse's notes.

Condition F reason:

The patient is most likely experiencing pressure injuries, as indicated by the redness on his heels and coccyx, which are common sites for pressure ulcers due to immobility.

Condition G reason:

There is no evidence of elder abuse in the patient's history or nurse's notes. Condition H reason:

Altered nutrition may be a concern due to the patient's reported difficulty eating full meals and less than optimal intake, but it is not the primary condition indicated by the nurse's assessment.

Condition I reason:

There is no evidence of bowel obstruction; the patient's main issue seems to be related to pressure injury and incontinence.

Parameter J reason:

Monitoring wound status is crucial for managing and tracking the healing process of any existing or potential pressure injuries.

Parameter K reason:

While documentation of skin prevention measures is important, it is not as immediate as monitoring wound status and incontinence episodes.

Parameter L reason:

Monitoring incontinence episodes will help evaluate the effectiveness of the bowel training program and any other interventions put in place to manage the patient's incontinence.

Parameter M reason:

Vital signs should always be monitored, but they are not specific to assessing the progress of pressure injury management or bowel training program effectiveness.

Parameter N reason:

Family dynamics are not relevant in this case as the patient lives alone and there is no indication of family involvement in his care.