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: While chest physiotherapy can help mobilize secretions, it does not specifically promote the flow of secretions to the base of the lungs. The primary goal is to loosen and mobilize secretions so they can be coughed up and cleared from the airways. This helps improve overall lung function and oxygenation.

Choice B reason: Chest physiotherapy does not eliminate the need to cough. In fact, coughing is an essential part of the process as it helps expel the loosened secretions from the airways. The therapy aims to make coughing more effective by loosening the mucus.

Choice C reason: The primary purpose of chest physiotherapy with percussion and vibration is to help clear the airways of excessive secretions. This is particularly important for patients with conditions like chronic obstructive pulmonary disease (COPD), cystic fibrosis, or pneumonia, where mucus buildup can obstruct the airways and impair breathing. By loosening and mobilizing the secretions, the therapy facilitates their removal through coughing.

Choice D reason: Chest physiotherapy does not limit the production of bronchial mucus. It focuses on clearing existing mucus from the airways rather than reducing its production. The production of mucus is influenced by underlying conditions and may require other treatments to manage.

Choice A Reason:

Sleep deprivation is incorrect. While sleep deprivation can cause confusion and disorientation, it is less likely to cause abrupt onset of altered mental status and hallucinations. Sleep deprivation typically results in gradual cognitive decline and fatigue rather than sudden changes.

Choice B Reason:

Normal signs of aging is incorrect. Normal aging can involve some cognitive decline, but it does not typically cause sudden and severe symptoms like hallucinations and significant disorientation. These symptoms are more indicative of an acute condition.

Choice C Reason:

Dementia is incorrect. Dementia involves a gradual decline in cognitive function over time and does not typically present with sudden onset of symptoms. While dementia can include hallucinations and disorientation, these symptoms usually develop progressively.

Choice D Reason:

Delirium is correct. Delirium is characterized by a sudden onset of confusion, disorientation, and changes in mental status. It is often triggered by acute medical conditions such as infections, including UTIs. Elderly patients are particularly susceptible to delirium, which can include symptoms like hallucinations and severe confusion.