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Difficulty: MediumBasic Care and Comfort

A nurse is preparing to provide a complete bed bath for a client who is receiving continuous enteral nutrition via a nasogastric tube. The procedure requires lowering the head of the bed to a supine position. Which of the following actions is the most appropriate for the nurse to take to ensure client safety?

  1. Pause the continuous enteral feeding pump before lowering the head of the bed.Answer
  2. B
    Turn the client to a left lateral recumbent position while the feeding continues to infuse.
  3. C
    Delegate the bathing procedure to an unlicensed assistive personnel (UAP) without altering the infusion.
  4. D
    Apply bilateral soft wrist restraints to prevent tube dislodgment during the position change.

Answer

The most appropriate action is to pause the continuous enteral feeding pump before lowering the head of the bed to prevent aspiration.
Pausing the continuous enteral feeding is the critical safety intervention before lowering the head of the bed. Standard nursing practice mandates that the head of the bed must remain elevated at 30 to 45 degrees during continuous enteral feeding to minimize the risk of aspiration pneumonia. If the bed must be lowered flat for hygiene care, turning, or repositioning, the feeding must be paused until the client's head can be safely elevated again.

Step-by-Step Solution

1
Identify the primary physiological risk associated with the procedure.
Lowering the head of the bed for a bed bath in a client receiving continuous enteral nutrition creates a high risk for pulmonary aspiration.
Enteral formula can easily reflux into the esophagus and enter the lungs if the client is not appropriately elevated at an angle of at least 30 to 45 degrees.
2
Determine the necessary nursing intervention to mitigate the risk.
The nurse must stop the flow of the enteral feeding.
Pausing the pump temporarily eliminates the introduction of new formula into the stomach while the client is flat, effectively protecting the airway during the bath.

Key Concept

Aspiration Precautions during Enteral Feeding
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Topics

Basic Care and Comfort

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