A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

Rationale:

A. Temperature 37.7° C (99.9° F): This temperature is only slightly elevated and not strongly indicative of infection. Endometritis typically presents with a fever above 38°C (100.4°F), reflecting a more pronounced inflammatory response.

B. Polyuria: Increased urine output is not a characteristic sign of endometritis. It may be seen with conditions such as diabetes mellitus or post-diuresis but is unrelated to uterine infection.

C. Malodorous lochia: Foul-smelling lochia is a key clinical sign of endometritis, indicating infection of the uterine lining. It often accompanies uterine tenderness, fever, and possibly abdominal pain.

D. Heart rate 56/min: Bradycardia is not typical in endometritis. Instead, clients may present with tachycardia as part of the systemic inflammatory response to infection. A low heart rate would be unexpected.

Rationale:

A. 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 by preventing gastric contents from entering the airway, especially during and after feeding.

B. Check gastric residuals every 4 hr: Regular residual checks help assess gastric emptying and tolerance of enteral feeding. High residuals may indicate delayed gastric motility and require intervention.

C. Check placement of the feeding tube by x-ray once daily: An x-ray is used only once to confirm initial tube placement. Daily x-rays are unnecessary unless dislodgement is suspected; routine placement verification is done via pH testing or aspiration.

D. Ensure the formula is cold before administration: Cold formula can cause cramping or discomfort. It should be at room temperature before administration to promote tolerance and reduce gastrointestinal side effects.

E. Change the feeding container and tubing every 24 hr: Changing feeding equipment every 24 hours prevents microbial contamination, especially with continuous feeding, and is consistent with infection control guidelines.