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Question

Difficulty: EasyReduction of Risk Potential

A nurse is preparing to initiate a continuous enteral tube feeding for an immobile client. To effectively reduce the risk of potentially life-threatening respiratory complications, which action must the nurse take?

  1. A
    Position the client completely flat in a supine alignment to promote gastrointestinal transit.
  2. Maintain the head of the bed elevated at 30 to 45 degrees throughout the infusion.Answer
  3. C
    Firmly palpate the client's abdomen for distention prior to auscultating for bowel sounds.
  4. D
    Delegate the assessment of gastric residual volume to an unlicensed assistive personnel (UAP).

Answer

The nurse must maintain the head of the bed elevated at 30 to 45 degrees throughout the continuous enteral feeding.
Elevating the head of the bed to at least 30 to 45 degrees is a fundamental nursing intervention that uses gravity to keep enteral formula within the stomach. This significantly reduces the risk of regurgitation and subsequent pulmonary aspiration, which is a common and highly dangerous complication of tube feedings.

Step-by-Step Solution

1
Identify the primary physiological risk associated with continuous enteral tube feedings.
The most significant risk is regurgitation of the liquid formula leading to pulmonary aspiration.
Immobile clients have a diminished ability to clear their airway if stomach contents back up into the esophagus.
2
Determine the most effective nursing intervention to physically prevent this complication.
Positioning the client upright utilizes gravity to contain the fluid.
Maintaining the head of the bed at 30 to 45 degrees ensures formula stays in the stomach, directly reducing the risk potential for aspiration.

Key Concept

Aspiration Prevention in Enteral Feedings
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Topics

Reduction of Risk Potential

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