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. Observing the client is inappropriate as they are demonstrating signs of choking and require immediate intervention.
B. Performing the Heimlich maneuver is appropriate as the guest is unable to talk, which indicates a potential airway obstruction that needs to be relieved promptly.
C. Slapping the client on the back may not be effective and could worsen the obstruction, especially since they are grasping their throat.
D. Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate in this situation, as the priority is to clear the obstruction, not to provide rescue breaths.
Correct Answer is D
Explanation
A. Assessing the pedal pulses with a Doppler device is not necessary in this situation; the focus should be on the apical pulse due to the irregularity noted in the radial pulse.
B. Assessing the pedal pulses for a full minute does not address the irregularity of the radial pulse and is not the priority.
C. While assessing the apical pulse is appropriate, using a Doppler device is not required unless there are difficulties in obtaining the pulse normally.
D. Assessing the apical pulse for a full minute is the correct action because it provides a more accurate reflection of the heart's rhythm and rate, especially when there is an irregular radial pulse.