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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Keeping the client's bed in the lowest position helps minimize the potential fall distance if the client attempts to get out of bed.
B. Assessing the client every 4 hours is a good practice for general monitoring but may not be specific to fall prevention. More frequent assessments may be necessary for a client at high risk for falls.
C. Keeping the client's room dark at night can actually increase the risk of falls. It's important to ensure there is adequate lighting to help the client navigate safely.
D. Teaching the client to use the call light allows them to request assistance when needed, reducing the likelihood of attempting to move or get out of bed independently.
E. Placing a fall-risk identification band on the client's wrist helps alert all healthcare providers that the client is at risk for falls. This information is crucial for ensuring appropriate precautions are taken.
Correct Answer is C
Explanation
A. The nurse is not responsible for obtaining informed consent. This is the responsibility of the healthcare provider performing the procedure, who must explain the risks, benefits, and alternatives to the client. The nurse may assist in ensuring the client has the necessary information, but the final responsibility for obtaining consent lies with the provider.
B. Explaining the risks and benefits of the procedure is part of the informed consent process.
The client needs to be informed about potential risks, benefits, and alternatives before giving consent.
C. This is correct. The nurse's role in the informed consent process is to witness the client's signature after the healthcare provider has explained the procedure, risks, and benefits. The nurse verifies that the client is signing voluntarily and understands the consent form, but the nurse does not provide the explanation.
D. Explaining the procedure to the client if they do not understand is essential for ensuring that the client has sufficient information to make an informed decision. This should be done in a clear and understandable manner.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today