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Difficulty: MediumReduction of Risk Potential

During a routine safety and assessment round on a medical-surgical unit, a nurse evaluates four clients. Which of the following observations indicates a severe physiological risk that requires immediate intervention by the nurse?

  1. A client receiving continuous enteral nutrition via a nasogastric tube who is positioned completely flat in a supine posture.Answer
  2. B
    A client with a chest drainage system whose water-seal chamber demonstrates gentle tidaling that corresponds with the respiratory cycle.
  3. C
    A client on a continuous intravenous heparin infusion for a deep vein thrombosis whose most recent activated partial thromboplastin time (aPTT) is 6565 seconds.
  4. D
    A client recovering from a severe asthma exacerbation with an arterial blood gas result showing a pH of 7.427.42, a PaCO2PaCO_2 of 3939 mmHg, and an HCO3−HCO_3^- of 2424 mEq/L.

Answer

The client receiving continuous enteral nutrition via a nasogastric tube positioned flat in a supine posture requires immediate intervention.
The correct answer identifies a severe physiological risk. Clients receiving continuous enteral feedings must be maintained with the head of the bed elevated at least 3030 to 4545 degrees. A completely flat, supine position significantly increases the risk of gastric reflux and pulmonary aspiration, which can lead to life-threatening aspiration pneumonia and acute respiratory distress. The nurse must immediately intervene to elevate the head of the bed.

Step-by-Step Solution

1
Evaluate the physiological risk associated with the client receiving continuous enteral nutrition.
A completely flat, supine position during continuous tube feeding poses an immediate and high risk for pulmonary aspiration.
The head of the bed must be elevated at least 3030 to 4545 degrees to utilize gravity in preventing formula from refluxing into the airway.
2
Analyze the assessment finding of the chest drainage system.
Gentle tidaling in the water-seal chamber is confirmed to be an expected, normal finding of a patent system.
Normal interpleural pressure fluctuations cause the water level to gently rise and fall with breathing.
3
Assess the laboratory values for the remaining clients.
The aPTT of 6565 seconds is therapeutic for heparin therapy, and the ABG values (pH 7.427.42, PaCO2PaCO_2 3939, HCO3−HCO_3^- 2424) are completely normal.
Since these values indicate clinical stability, neither of these clients requires an immediate corrective intervention.

Key Concept

Prioritization and Reduction of Risk Potential (Aspiration Prevention)
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Topics

Reduction of Risk Potential

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