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. Giving the medication that is expired poses a risk to the client, as the safety and efficacy of the medication cannot be guaranteed past its expiration date.
B. Returning the medication to the pharmacy may not be feasible in this scenario; proper disposal is generally the nurse's responsibility for expired medications.
C. Discarding the medication is the appropriate action to ensure client safety, as expired medications should not be administered.
D. Notifying the provider is unnecessary in this case; the nurse's responsibility is to discard the expired medication and prepare a new dose that is within its expiration date.
Correct Answer is C
Explanation
A. Alcohol-based hand sanitizers are not effective against C. difficile spores; hand hygiene should be performed using soap and water to effectively remove the spores.
B. Testing for C. difficile typically involves stool samples, not blood specimens, making this option inappropriate for confirming the infection.
C. Placing the client on contact precautions is essential to prevent the spread of C. difficile, as it is highly contagious and can be transmitted via surfaces and direct contact.
D. A surgical mask is not necessary for clients with C. difficile unless they have respiratory symptoms; the primary concern is preventing contact transmission.