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 D
Explanation
A. Contacting the pharmacy may provide information, but the nurse's primary responsibility is to clarify the prescription with the provider, as they ordered the medication.
B. Informing the charge nurse and administering the medication without verifying the dosage is inappropriate and could potentially harm the client.
C. Asking another nurse to verify the dosage is a good practice but does not address the need for clarification from the provider.
D. Contacting the provider to question the dosage is the correct action, as it ensures patient safety by confirming the appropriateness of the prescribed dose before administration.
Correct Answer is A
Explanation
A. Applying petroleum jelly to the client's lips after oral care helps to prevent dryness and cracking, especially important for immobile clients who may have decreased hydration.
B. A stiff toothbrush can cause damage to the gums and teeth; a soft-bristled toothbrush is preferable for gentle cleaning.
C. Using the thumb and index finger to keep the client's mouth open can cause discomfort; a tongue blade or a mouth prop may be a better option if needed.
D. While turning the client on their side can help if there is a risk of aspiration, it is not always necessary for every oral care session and depends on the client's specific condition.