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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?

A.

Check residual volume every 4 to 6 hr.

B.

Observe client's respiratory status.

C.

Elevate the head of the client's bed 30° to 45°.

D.

Monitor intake and output every 8 hr.

Answer and Explanation

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 A

Explanation

A. Urinary frequency for several days is an expected outcome after catheter removal, as the bladder may become more sensitive and responsive after having been drained continuously.

B. While temporary urinary retention can occur, it is less common after short-term catheterization, and most clients will start voiding normally within a few hours.

C. Blood-tinged urine may occur occasionally, but it is not a typical expected outcome unless there was trauma or irritation during catheterization.

D. Highly concentrated urine can occur due to dehydration or lack of fluid intake, but it is not a specific expected outcome following catheter removal.

Correct Answer is A

Explanation

A. Discarding the tablet and obtaining another dose is the safest option, as it ensures the medication's integrity and prevents any potential contamination.

B. Using the tablet's packaging to pick it up is not appropriate as it could introduce contaminants from the surface of the counter to the tablet.

C. Washing the tablet with alcohol is not advisable because it could alter the medication's properties or effectiveness.

D. Placing the tablet directly into a medication cup without addressing its contamination would also be inappropriate and could jeopardize client safety.

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