A nurse is collecting data from a client who has heart failure.
The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min.
Which of the following actions should the nurse take?

Answer isc. Keep the head of the bed raised while the tube feeding is infusing.

The client has a gastrostomy tube (GT), which is a tube inserted through the abdomen into the stomach for feeding purposes1.The PN should instruct the UAP to keep the head of the bed raised at least 30 degrees while the tube feeding is infusing, to prevent aspiration of the feed into the lungs2.Aspiration can cause pneumonia, which is a serious complication that can be fatal3.

a. Raising the entire bed while bathing the client to reduce back strain is not the most important instruction, because it does not address the risk of aspiration. The PN should also consider the client’s comfort and safety when adjusting the bed height. b. Reporting any drainage observed around the GT insertion site is not the most important instruction, because it is not directly related to the tube feeding. Drainage may indicate infection or leakage of the feed, which should be reported and managed accordingly. d. Using plenty of pillows to position the client on the side after bathing is not the most important instruction, because it is not specific to the tube feeding. Positioning the client on the side may help prevent pressure ulcers and improve circulation, but it does not prevent aspiration.

The correct answer is Choice A. Notify the charge nurse about the situation.

Choice A rationale: This is the correct answer because the nurse should notify the charge nurse or the provider who is responsible for obtaining informed consent from the client. The nurse cannot obtain informed consent from a client who does not understand the purpose, risks, benefits, and alternatives of the procedure. The nurse should also respect the client’s right to refuse or withdraw consent at any time. By notifying the charge nurse or the provider, the nurse ensures that the client receives adequate information and clarification before giving consent.This is consistent with the ethical and legal principles of informed consent in nursing

Choice B rationale: This is incorrect because the nurse should not ask the client to sign the consent form anyway. This would violate the client’s autonomy and right to make informed decisions about their health. It would also expose the nurse and the provider to legal and ethical consequences for performing a procedure without valid consent. The nurse should ensure that the client understands the information provided and agrees to the procedure voluntarily. Asking the client to sign the consent form anyway would undermine the trust and communication between the client and the healthcare team.

Choice C rationale: This is incorrect because the nurse should not explain to the client that the procedure will help treat his diagnosis. This is not the nurse’s role or responsibility in the process of obtaining informed consent. The nurse should not provide information that is beyond their scope of practice or expertise. The nurse should also not persuade or coerce the client to agree to the procedure. The nurse should refer the client to the provider who can explain the rationale and evidence for the procedure and answer any questions or concerns the client may have.

Choice D rationale: This is incorrect because the nurse should not remind the client about the specifics of the procedure. This is not the nurse’s role or responsibility in the process of obtaining informed consent. The nurse should not repeat or restate information that the provider has already given to the client. The nurse should also not assume that the client has forgotten or misunderstood the information. The nurse should respect the client’s right to ask questions and seek clarification from the provider who can provide accurate and comprehensive information about the procedure.