A home health nurse is caring for an older adult client who reports. "I keep coughing when I try to swallow my food, but not at other times." Which of the following actions should the nurse take?

Rationale:

A. “I should advise a client about what I feel to be his best health care decision.": Advocacy involves supporting the client’s choices and rights, not imposing the nurse’s personal opinions. Advising based on personal beliefs undermines the client’s autonomy and is not consistent with professional advocacy.

B. "I should not advocate for a client unless he is able to ask me himself.": Client advocacy includes speaking up on behalf of clients who cannot voice their own needs, such as those who are incapacitated or vulnerable. Waiting for the client to ask would neglect the nurse’s responsibility to protect and support the client.

C. “I will intervene if there is a conflict between a client and his provider.": Advocacy involves intervening when a client’s rights, preferences, or safety are at risk, including resolving conflicts with providers. This demonstrates understanding of the nurse’s role in ensuring the client’s voice is heard and needs are met.

D. “I will inform a client that his family should help make his health care decisions.": While family input can be important, the client’s autonomy takes priority. Encouraging family decision-making over the client’s choices does not reflect proper advocacy and may compromise the client’s rights.

Rationale:

A. Check gastric residuals every 4 hr: Monitoring gastric residual volume every 4 hours helps assess tolerance to enteral feeding and reduces the risk of aspiration. High residuals may indicate delayed gastric emptying, requiring adjustment of the feeding regimen or provider notification.

B. Check placement of the feeding tube by x-ray once daily: X-ray is the gold standard for initial confirmation of tube placement, not for routine daily checks. Ongoing verification is typically done by assessing pH of gastric aspirate and observing for signs of misplacement, making daily x-rays unnecessary and impractical.

C. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed reduces the risk of aspiration during continuous enteral feedings. Proper positioning is a key intervention to promote safety and prevent complications such as pneumonia.

D. Change the feeding container and tubing every 24 hr: Changing the feeding container and tubing every 24 hours helps prevent bacterial contamination and infection. This is a standard infection-control measure in enteral feeding care.

E. Ensure the formula is cold before administration: Formula should be at room temperature before administration. Cold formula can cause gastrointestinal discomfort, cramping, and nausea, so heating it to room temperature improves tolerance and safety.