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 D
Explanation
A. Kussmaul respirations are characterized by deep, rapid breathing typically associated with metabolic acidosis, not alternating periods of hyperventilation and apnea.
B. Apneustic respirations involve prolonged inspiration and shorter expiration phases, usually seen in brain injuries, but do not reflect alternating hyperventilation and apnea.
C. Stridor is a high-pitched wheezing sound indicative of upper airway obstruction, which does not describe the breathing pattern in this scenario.
D. Cheyne-Stokes respirations are defined by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of no breathing (apnea), making this the correct choice for the client’s described pattern.
Correct Answer is A
Explanation
A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.
B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.
C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.
D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.