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Difficulty: EasyBasic Care and Comfort

A nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. Which of the following positions is the most appropriate for this client to prevent complications?

  1. Semi-Fowler's position with the head of the bed elevated 30 to 45 degreesAnswer
  2. B
    Supine position with a small pillow supporting the head and neck
  3. C
    Left lateral Sims' position with the bed kept completely flat
  4. D
    Trendelenburg position to promote optimal gastric emptying

Answer

Semi-Fowler's position with the head of the bed elevated 30 to 45 degrees
Elevating the head of the bed to 30 to 45 degrees (semi-Fowler's position) is a foundational standard of care for clients receiving continuous enteral feedings. This position uses gravity to keep the formula in the stomach, thereby reducing the risk of gastric reflux and life-threatening aspiration pneumonia.

Step-by-Step Solution

1
Identify the client's current treatment and the primary associated risk.
The client is receiving continuous enteral nutrition via a nasogastric tube. The major complication associated with this therapy is pulmonary aspiration of the feeding formula.
Recognizing the most critical safety risk determines the priority nursing intervention.
2
Determine the physiological mechanism needed to mitigate the risk.
Gravity must be utilized to keep the liquid formula within the stomach and prevent it from traveling back up the esophagus.
Non-pharmacological positioning is the standard first-line defense against aspiration.
3
Select the client position that best achieves this gravitational benefit.
Elevating the head of the bed to a 30 to 45-degree angle (semi-Fowler's position) provides the necessary elevation to prevent reflux.
This specific angle safely prevents aspiration while maintaining client comfort and minimizing shear forces on the sacral skin.

Key Concept

Prevention of aspiration during enteral feeding via proper positioning
Estimated Time:45s
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Topics

Basic Care and Comfort

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