A nurse is caring for a patient who has impaired speech. What actions should the nurse take?

Choice A rationale

Discarding the dressing in the bedside trash receptacle is not recommended because it can lead to the spread of infection. The dressing is contaminated with blood and purulent drainage, which are considered biohazardous waste.

Choice B rationale

Double-bagging the dressing in clear bags and labeling it “biohazard” is not sufficient. While it’s important to label biohazardous waste, the dressing should be disposed of in a designated biohazardous waste container.

Choice C rationale

Enclosing the dressing in a single clear plastic bag and discarding it in the bedside trash receptacle is also not recommended. This method does not provide adequate containment for biohazardous waste.

Choice D rationale

Disposing of the dressing in a biohazardous waste container is the correct method. This ensures that the biohazardous waste is properly contained and reduces the risk of spreading infection.

Choice A rationale

While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.

Choice B rationale

Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.

Choice C rationale

Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.

Choice D rationale

Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.