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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. Trying to defecate at different times of the day may not be effective; it's better to establish a regular bowel routine.
B. Increasing daily fluid intake is correct, as adequate hydration helps soften stool and promote regular bowel movements, making it an essential part of managing constipation.
C. Reducing daily activity is incorrect; regular physical activity can stimulate bowel function and alleviate constipation.
D. Consuming a low-fiber diet is not advisable, as a high-fiber diet is recommended for preventing and managing constipation by promoting healthy bowel movements.
Correct Answer is D
Explanation
A. Shaving the hair off the skin where the electrodes will be placed is correct, as it helps ensure proper contact and effectiveness of the TENS therapy.
B. Expressing hope to reduce the need for pain pills indicates the client understands the potential benefit of TENS in managing pain.
C. Wishing to avoid attaching electrodes indicates a common apprehension about the treatment but does not necessarily signify a misunderstanding of the TENS process.
D. The statement about having to be in the hospital suggests a misunderstanding since TENS is often used as an outpatient therapy and does not typically require hospitalization. This indicates the client needs further education about the treatment setting and process.