A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?
Observe the client's respiratory status.
Monitor intake and output every 8 hr.
Elevate the head of the client's bed 30° to 45°.
Check residual volume every 4 to 6 hr.
The Correct Answer is C
A. Observing the client's respiratory status is also important, but it is an ongoing assessment rather than an immediate action.
B. Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.
C. This is crucial to prevent aspiration, which can occur if the feeding formula enters the lungs, leading to pneumonia or other serious complications. Elevating the head of the bed helps keep the esophagus above the stomach, reducing the risk of aspiration.
D. Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.
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Related Questions
Correct Answer is C
Explanation
A. Measuring the gastric residual is a common practice before administering enteral feedings. It helps to assess if the client's stomach is emptying properly and if there is any buildup of undigested formula. This is important in identifying delayed gastric emptying, which can lead to complications if not addressed.
B. To remove gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. The main concern is to assess the rate of stomach emptying.
C. To confirm the placement of the NG tube is typically done using other methods, such as pH testing or an X-ray. While aspirating stomach contents through the tube can help confirm placement, it is not the primary purpose of measuring gastric residual.
D. To determine the client's electrolyte balance is not related to the purpose of measuring gastric residual. Electrolyte balance is typically assessed through blood tests and clinical signs and symptoms.
Correct Answer is ["A","C","D"]
Explanation
Rationale A: Assisting a client to ambulate using a gait belt is a task within the scope of practice for assistive personnel. It involves physical support and monitoring, which do not require the advanced training of a registered nurse. This task ensures the client's safety while promoting mobility.
Rationale B: Reviewing a low-sodium diet is not within the scope of practice for assistive personnel as it requires nutritional knowledge and the ability to teach, which are responsibilities of a registered nurse or a dietitian.
Rationale C: Feeding a client who had a stroke 3 months ago can be delegated to assistive personnel. This task does not require the clinical judgment of a nurse and can be performed following a predefined plan of care.
Rationale D: Bathing a client who had an amputation 2 days ago can be delegated to assistive personnel. They are trained to assist with activities of daily living, including bathing, while ensuring the client's safety and comfort.
Rationale E: Explaining oral hygiene to a client receiving chemotherapy involves patient education and understanding of the specific needs related to the client's condition, which are beyond the role of assistive personnel. This task requires the expertise of a nurse or other healthcare professional.
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