Difficulty: Medium
Average Score: 70%
Simulated
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?
Correct answer
C
Rationale
The correct answer is C: Elevate the head of the client's bed 30┬░ to 45┬░. This is the priority action because it helps prevent aspiration in a client with decreased consciousness receiving enteral feedings. By elevating the head of the bed, gravity helps keep the feeding in the stomach and reduces the risk of reflux into the lungs, which can lead to aspiration pneumonia.
Checking residual volume (choice A) is important but not the priority. Observing respiratory status (choice B) is also crucial but secondary to preventing aspiration. Monitoring intake and output (choice D) is a routine nursing task but not as critical as preventing aspiration. The key is to prioritize actions that directly impact the client's safety and well-being, which in this case is elevating the head of the bed.
Checking residual volume (choice A) is important but not the priority. Observing respiratory status (choice B) is also crucial but secondary to preventing aspiration. Monitoring intake and output (choice D) is a routine nursing task but not as critical as preventing aspiration. The key is to prioritize actions that directly impact the client's safety and well-being, which in this case is elevating the head of the bed.