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. Performing the final medication check in the area where the medication was obtained does not ensure the correct patient is receiving the medication.
B. Documenting after administration does not allow for a final check of the medication against the patient’s identity and allergies.
C. Performing the final check at the client's bedside before administration allows the nurse to confirm the patient's identity, the medication's appropriateness, and the dosage immediately before giving it.
D. Reviewing the prescription at the nurses' station may not account for patient-specific factors that need to be confirmed at the bedside.
Correct Answer is C
Explanation
A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.
B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.
C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.
D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.