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. 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.
Correct Answer is D
Explanation
A. Using each cleansing wipe twice is not appropriate, as this may cause cross-contamination; each wipe should be used once.
B. Cleaning the inside of the container is unnecessary and may introduce contaminants; only the outside should be kept clean.
C. The correct method involves urinating a little, stopping to allow for midstream collection, and then continuing to urinate; saying "then stop" may confuse the procedure.
D. Using the cleansing wipe from front to back is the correct technique for women to prevent urinary tract infections (UTIs) and ensure proper hygiene during sample collection.