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Difficulty: MediumBasic Care and Comfort

A dependent client is receiving a continuous enteral tube feeding via a nasogastric tube. The care team needs to perform a complete bed bath and change the linens, which requires placing the client in a flat, supine position. Which nursing action is the highest priority before lowering the head of the bed?

  1. A
    Flush the nasogastric tube with 30 mL of sterile water.
  2. B
    Auscultate the client's abdomen to verify the presence of normal bowel sounds.
  3. Halt the enteral feeding pump to stop the continuous infusion.Answer
  4. D
    Assign the unlicensed assistive personnel to assess the client's airway during the procedure.

Answer

The highest priority action is to halt the enteral feeding pump to stop the continuous infusion before lowering the head of the bed.
When a client is receiving a continuous enteral feeding, the head of the bed must remain elevated at least 30 to 45 degrees to utilize gravity in preventing gastric reflux and subsequent pulmonary aspiration. Because the bed bath and linen change require placing the client in a flat, supine position, the nurse must first halt the feeding pump. This prioritized action directly protects the client's airway during the procedure.

Step-by-Step Solution

1
Identify the primary physiological risk associated with the planned positional change.
Lowering the head of the bed for a client with an active enteral feeding significantly increases the risk of gastric reflux and pulmonary aspiration.
Gravity is required to keep gastric contents from flowing back up the esophagus when the stomach is receiving continuous liquid nutrients.
2
Determine the necessary preventative nursing action.
The continuous feeding must be temporarily stopped.
Halting the infusion ensures that no new volume is added to the stomach while the client is supine, thereby protecting the airway.
3
Evaluate other options against the highest priority of airway protection.
Flushing the tube or assessing bowel sounds do not protect the airway. Delegating an airway assessment is legally out of scope for assistive personnel.
Airway protection (ABC priority) must always precede routine maintenance or delegation tasks.

Key Concept

Aspiration Prevention during Enteral Nutrition Administration
Estimated Time:1m 0s
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Topics

Basic Care and Comfort

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