The nurse is continuing to care for the client.

Exhibits

A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed?
For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Rationale:
A. The client agreed to the procedure voluntarily: By witnessing the signature, the nurse verifies that the client is signing the consent form without coercion, fulfilling the legal requirement that consent is given voluntarily. This does not require the nurse to provide detailed explanations of the procedure.

B. The nurse explained the surgical procedure in detail: The responsibility for explaining the procedure, risks, and benefits lies with the surgeon or provider, not the nurse witnessing the consent. Witnessing only confirms voluntary agreement.

C. The nurse explained the risks and benefits of the surgery: Explaining risks and benefits is the provider’s legal obligation. The nurse’s role is to witness the client’s signature, not to provide detailed medical explanations.

D. The client knows they may no longer refuse the procedure: Clients always retain the right to refuse a procedure, even after signing consent. Witnessing does not override the client’s autonomy or ability to change their mind.

Rationale:
A. Provide a pacifier for nonnutritive sucking: Offering a pacifier promotes nonnutritive sucking, which supports oral motor development and provides comfort for the infant during gastrostomy tube feedings. This practice can help the infant transition more easily to oral feeding later.

B. Warm the formula in the microwave prior to administration: Warming formula in the microwave is unsafe because it can create hot spots that may burn the infant’s mouth or esophagus. Formula should be warmed using a bottle warmer or by placing the container in warm water.

C. Change the gastrostomy tube every 3 days: Routine gastrostomy tube replacement every 3 days is unnecessary and can cause trauma. Tubes are generally changed according to manufacturer recommendations or when malfunction or blockage occurs.

D. Place the infant in a supine position after the feeding: Infants should be kept in an upright or semi-upright position during and after feedings to reduce the risk of aspiration. Supine positioning increases the likelihood of reflux and respiratory complications.