A nurse is developing a care plan for a patient with a decreased level of consciousness who is receiving continuous enteral feedings through a gastrostomy tube due to an inability to swallow.
What should be the nurse’s priority action?
Observe the patient’s respiratory status.
Elevate the head of the patient’s bed 30° to 45°.
Monitor intake and output every 8 hours.
Check residual volume every 4 to 6 hours.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Chilling the irrigant prior to the procedure is not recommended. Cold irrigant can cause discomfort and potentially lead to vasoconstriction, which can impede the healing process.
Choice B rationale
Irrigating the wound until the solution that is draining is clean is a standard practice in wound care. This helps to ensure that all debris and potential contaminants are removed from the wound.
Choice C rationale
Holding the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating is not a standard practice. The syringe should be held close to the wound to ensure effective irrigation.
Choice D rationale
Flushing the wound from the most contaminated area to the cleanest area is not a standard practice. The wound should be irrigated from the cleanest to the dirtiest area to prevent the spread of contamination.
Correct Answer is C
Explanation
Choice A rationale
While a patient’s medication history can impact wound healing, in this case, there is no specific information provided about the patient’s medications that would suggest a delay in wound healing.
Choice B rationale
Although the patient’s cholesterol level is elevated, hyperlipidemia is not typically associated with delayed wound healing.
Choice C rationale
Prealbumin is a marker of nutritional status. A low prealbumin level, like in this patient, could indicate malnutrition, which can delay wound healing. Adequate nutrition is essential for wound healing as it provides the necessary building blocks for tissue repair.
Choice D rationale
The patient’s fasting glucose level is within the normal range, so it is unlikely to impact wound healing. While poorly controlled diabetes can delay wound healing, this patient’s diabetes appears to be well-controlled.
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