A nurse administers 200 mL of enteral nutrition via a client’s gastrostomy (GT) tube. The nurse flushes the feed bolus with 30 mL of water before and after the feed. How many mL does the nurse document as intake in the I&O?

(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Choice A Reason:

The client’s immediate family members may not always have the right to access the client’s protected health information (PHI) unless the client has given explicit consent. Confidentiality laws, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States, are designed to protect the privacy of patients’ health information. These laws generally require that PHI be shared only with individuals who are directly involved in the patient’s care or who have been authorized by the patient. Therefore, while family members may be involved in the patient’s care, they do not automatically have the right to access PHI without the patient’s consent.

Choice B Reason:

The facility’s administrators typically do not need access to a specific client’s PHI unless it is necessary for administrative purposes related to the patient’s care or for compliance with legal and regulatory requirements. Administrators are generally more involved in the overall management and operation of the healthcare facility rather than in the direct care of individual patients. Sharing PHI with administrators without a valid reason could violate confidentiality laws and the patient’s right to privacy.

Choice C Reason:

Health care team members caring for the client are directly involved in the patient’s care and, therefore, have a legitimate need to access the client’s PHI. This includes doctors, nurses, therapists, and other healthcare professionals who are providing treatment, coordinating care, or ensuring the patient’s well-being. Sharing PHI with these individuals is essential for delivering safe and effective care, and it is permitted under confidentiality laws such as HIPAA.

Choice D Reason:

Clergy affiliated with the facility may provide spiritual support to patients, but they do not typically have a legitimate need to access the client’s PHI unless the patient has given explicit consent. While spiritual care is an important aspect of holistic healthcare, it does not require access to detailed medical information. Therefore, sharing PHI with clergy without the patient’s consent would generally be considered a violation of confidentiality laws.

Choice A Reason:

The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.

Choice B Reason:

The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.

Choice C Reason:

The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.

Choice D Reason:

The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.