A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of continuous infusions should the nurse initiate?

A. Ensure the formula is cold before administration. Enteral formula should be given at room temperature to avoid causing gastrointestinal cramping or discomfort. Cold formula can irritate the GI tract and lead to intolerance.
B. Check placement of the feeding tube by x-ray once daily. An x-ray is used initially to confirm tube placement after insertion, but daily x-rays are not required. Ongoing checks are done through aspirate checks and measuring external tube length.
C. Maintain the head of the client's bed at a 20° angle or higher. The head of the bed should be elevated to at least 30 to 45 degrees to prevent aspiration. A 20° angle is insufficient and increases the risk of aspiration pneumonia.
D. Check gastric residuals every 4 hr. This is appropriate for clients receiving continuous feedings. Monitoring gastric residual volume (GRV) every 4 hours helps assess tolerance to the feeding and reduces the risk of aspiration.
E. Change the feeding container and tubing every 24 hr. To prevent bacterial contamination, the feeding bag and tubing should be changed every 24 hours when using an open system. This is a standard infection control practice.

A. 1+ pedal edema. Mild pedal edema is typically not associated with instability or falls, unless it progresses to severe swelling that affects mobility or balance. It is a sign of fluid retention but not a direct fall risk indicator on its own.
B. Bruises on the lower extremities. Bruising can be a sign of previous falls or trauma, but it is not itself a cause or indicator of fall risk. While it may prompt further investigation, it does not confirm fall risk independently.
C. Impaired vision. Visual impairment is a significant risk factor for falls because it affects depth perception, ability to detect hazards, and overall spatial awareness. Clients with impaired vision are more likely to trip, misjudge steps, or bump into obstacles.
D. Coarse rhonchi auscultated over the trachea. Coarse rhonchi are respiratory findings typically related to mucus in the airways and do not directly contribute to fall risk unless accompanied by severe respiratory distress or fatigue.