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 B
Explanation
A. Mixing medications can alter their effectiveness and increase the risk of tube blockage. Each medication should be administered separately.
B. Flushing the NG tube with 30 mL of water after administering medications is important to ensure that the medications are cleared from the tube and absorbed properly by the patient. This also helps to prevent tube occlusion.
C. Diluting medications may not be necessary for all liquid medications, and it depends on the specific medication's guidelines. Each medication should be administered as directed.
D. The head of the bed should be elevated during and after medication administration to prevent aspiration. Keeping it flat is not recommended.
Correct Answer is C
Explanation
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.