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. Using an alcohol rub when hands are visibly soiled is incorrect; hands should be washed with soap and water in such cases.
B. Rubbing all surfaces of the hands with an alcohol rub for 20 to 30 seconds is an appropriate practice for effective hand hygiene when hands are not visibly soiled, ensuring thorough coverage of all hand surfaces.
C. Gloves are not a substitute for hand hygiene; hands should be washed before putting on gloves and after removing them to prevent contamination.
D. Even if an individual does not have an infection, they can still carry pathogens on their hands that may infect others, highlighting the necessity of proper hand hygiene.
Correct Answer is D
Explanation
A. Proceeding to measure the oral temperature immediately after the client has consumed ice chips can lead to an inaccurate reading due to the cooling effect of the ice.
B. Documenting that the nurse was unable to measure the client's temperature is unnecessary; it is possible to obtain an accurate measurement after a suitable waiting period.
C. Providing a sip of warm water will not resolve the issue of the ice chips affecting the temperature reading, as the nurse should still wait a longer period for accuracy.
D. Waiting 30 minutes after the client has consumed ice chips is the best practice, as it allows sufficient time for the oral cavity to return to a baseline temperature for an accurate measurement.