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Difficulty: MediumBasic Care and Comfort

A nurse is caring for a client who is receiving continuous enteral tube feedings and requires repositioning every 2 hours to prevent pressure injuries. Which of the following actions is the most appropriate for the nurse to take when turning the client?

  1. A
    Maintain the head of the bed at a 45-degree angle throughout the turning process.
  2. B
    Delegate the turning procedure to the unlicensed assistive personnel (UAP) without interrupting the feeding.
  3. Pause the continuous enteral feeding before lowering the head of the bed.Answer
  4. D
    Lower the head of the bed flat and quickly turn the client to the right side to promote gastric emptying.

Answer

Pause the continuous enteral feeding before lowering the head of the bed.
Pausing the enteral feeding before lowering the head of the bed is essential to prevent pulmonary aspiration of gastric contents. Repositioning requires the bed to be lowered to minimize shearing forces on the client's skin and to maintain proper body mechanics for the staff. However, because enteral feeding must always be stopped when the head of the bed is lower than 30 degrees, pausing the pump is the necessary first step.

Step-by-Step Solution

1
Identify the primary physiological risk for a client receiving continuous enteral feedings.
The highest risk is pulmonary aspiration of gastric contents if the head of the bed is lowered.
Enteral nutrition introduces liquid directly into the stomach, increasing the volume of gastric contents and the potential for reflux.
2
Determine the proper mechanics for safely turning a client in bed.
The head of the bed should be lowered to flat or nearly flat before turning.
Turning a client with the head of the bed elevated creates severe shearing forces on the sacrum, which causes pressure injuries and makes turning ergonomically difficult for the nurse.
3
Combine the safety requirements of both interventions (feeding and turning).
The feeding must be temporarily stopped so the head of the bed can be safely lowered for turning.
This dual approach prevents aspiration while also adhering to safe mobility and skin integrity practices.

Key Concept

Aspiration Prevention during Enteral Feeding and Mobility
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Topics

Basic Care and Comfort

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