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Difficulty: HardBasic Care and Comfort

An adult client who is immobile and 24 hours post-operative from a gastrostomy tube placement is receiving continuous enteral nutrition. When planning basic care and comfort measures, which actions should the licensed practical nurse (LPN) implement? Select all that apply.

  1. Maintain the head of the bed elevated at 30 to 45 degrees continuously.Answer
  2. Pause the enteral feeding pump prior to lowering the head of the bed for repositioning.Answer
  3. Apply a moisture barrier cream to the perineal skin after cleansing incontinent episodes.Answer
  4. D
    Lower the head of the bed to a flat, supine position for one hour after morning care while the feeding infuses.
  5. E
    Complete the initial comprehensive skin assessment of a newly discovered pressure injury on the sacrum.
  6. F
    Administer a prescribed as-needed analgesic for joint stiffness before clearing loud, gurgling respiratory secretions.

Answer

The appropriate actions for the LPN to implement are maintaining the head of the bed elevated at 30 to 45 degrees, pausing the feeding pump before lowering the head of the bed, and applying a moisture barrier cream after incontinence care.
Maintaining the head of the bed elevated at 30 to 45 degrees is essential to prevent regurgitation and aspiration during continuous enteral feedings. If the head of the bed must be lowered for turning or repositioning, the feeding pump must be paused first to protect the client's airway. Applying a moisture barrier cream to the perineal area after cleansing is a fundamental comfort measure that protects vulnerable skin from breakdown due to incontinence and immobility.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is immobile, post-operative, and receiving continuous enteral nutrition.
Identifying risk factors such as aspiration and skin breakdown guides the selection of safe basic care interventions.
2
Evaluate basic care and comfort interventions for safety and scope of practice.
Elevating the head of the bed, pausing feeds before repositioning, and applying moisture barrier creams are within the LPN scope and directly promote safety and skin integrity.
These actions prevent aspiration and manage moisture, which are critical basic care elements.
3
Identify and exclude contraindicated or out-of-scope actions.
Positioning the client flat while feeding, performing initial comprehensive assessments, and delaying airway clearance for pain management are unsafe or outside the LPN scope of practice.
LPNs must adhere to ABC prioritization, proper post-procedure positioning to protect the airway, and scope of practice limitations.

Key Concept

Basic Care and Comfort for Enteral Nutrition and Immobility
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Topics

Basic Care and Comfort

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