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?
Check residual volume every 4 to 6 hr.
Observe client's respiratory status.
Elevate the head of the client's bed 30° to 45°.
Monitor intake and output every 8 hr.
The Correct Answer is C
A. Checking residual volume is important for assessing tolerance to feedings, but it is not the priority action to prevent complications related to decreased consciousness.
B. Observing the client’s respiratory status is crucial but not the priority action related to enteral feedings.
C. Elevating the head of the client's bed 30° to 45° is the priority action, as it reduces the risk of aspiration during enteral feeding, which is a significant concern for clients with decreased consciousness.
D. Monitoring intake and output is important for overall assessment but is not the immediate priority in this context.
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Correct Answer is C
Explanation
A. Obtaining the client's consent is the responsibility of the provider, not the nurse. The nurse should ensure the client is informed but cannot independently obtain consent.
B. It is not within the nurse's scope of practice to explain the procedure in detail; this is the responsibility of the healthcare provider. The nurse can clarify information if the client has questions but should not assume the role of the educator regarding the procedure.
C. Witnessing the client's signature is an appropriate action for the nurse once the client has received information from the provider and understands the procedure, as it confirms that the client voluntarily consents.
D. Explaining the risks and benefits of the procedure is also the responsibility of the healthcare provider, as they are the ones performing the procedure and are qualified to discuss it in detail.
Correct Answer is C
Explanation
A. Giving the medication that is expired poses a risk to the client, as the safety and efficacy of the medication cannot be guaranteed past its expiration date.
B. Returning the medication to the pharmacy may not be feasible in this scenario; proper disposal is generally the nurse's responsibility for expired medications.
C. Discarding the medication is the appropriate action to ensure client safety, as expired medications should not be administered.
D. Notifying the provider is unnecessary in this case; the nurse's responsibility is to discard the expired medication and prepare a new dose that is within its expiration date.