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. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.
B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.
C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.
D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.
Correct Answer is A
Explanation
A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.
B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.
C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.
D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.