A hospice nurse is visiting with the son of a client who has terminal cancer.
The son reports sleeping very little during the past week due to caring for his mother.
Which of the following responses should the nurse make?

The correct answer is choice d. Privately interview the client about the injuries.

Choice A rationale:

Contacting the family regarding the client’s condition might not be appropriate if the family is suspected of being involved in the abuse. It could potentially put the client at further risk.

Choice B rationale:

Notifying risk management is important for documentation and internal review, but it does not directly address the immediate need to assess and ensure the client’s safety.

Choice C rationale:

Informing the transferring agency of the client’s condition is necessary for continuity of care, but it does not address the immediate need to investigate the cause of the injuries and ensure the client’s safety.

Choice D rationale:

Privately interviewing the client about the injuries allows the nurse to gather more information about the cause of the injuries in a safe and confidential manner. This step is crucial in assessing the situation and determining if further action, such as reporting to authorities, is needed. It ensures the client’s safety and helps in identifying any potential abuse.

The correct answer is Choice B.

Choice A rationale: Maintaining bed elevation at 20 degrees is not recommended. The recommended bed elevation for patients receiving enteral tube feedings is at least 30 to 45 degrees.This is to prevent aspiration of the feeding solution into the lungs.

Choice B rationale: Flushing the tubing with 30 mL of water every 4 hours is a recommended practice.This helps to maintain the patency of the feeding tube and prevent clogging.

Choice C rationale: Checking for gastric residual every 12 hours is not sufficient.For patients receiving continuous tube feedings, gastric residual volume (GRV) should be monitored every 4 hours.This helps to assess tolerance to the feeding and prevent complications such as aspiration.

Choice D rationale: Placing enough formula in the container to last 18 hours is not recommended.For an open system, the formula should be replaced every 4 hours to prevent bacterial growth.