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Question

Difficulty: EasyReduction of Risk Potential

An adult client admitted to the medical-surgical unit is currently receiving continuous enteral nutrition through a nasogastric tube. To actively reduce the risk of potential physiological complications associated with this therapy, which intervention is most appropriate for the nurse to implement?

  1. Keep the head of the bed raised between 30 and 45 degrees.Answer
  2. B
    Place the client in a completely supine position during periods of rest and sleep.
  3. C
    Assign an unlicensed assistive personnel to evaluate the client's gag reflex each shift.
  4. D
    Palpate the client's abdomen to assess for distention before auscultating for bowel sounds.

Answer

The correct intervention is to keep the head of the bed raised between 30 and 45 degrees to prevent the aspiration of enteral formula.
Keeping the head of the bed raised between 30 and 45 degrees uses gravity to prevent the reflux of gastric contents into the esophagus, thereby significantly reducing the risk of aspiration. Aspiration of enteral formula can lead to severe respiratory complications, such as aspiration pneumonia. This position must be maintained continuously while the feeding is active.

Step-by-Step Solution

1
Identify the primary therapy and its associated risks.
The client is receiving continuous enteral nutrition via a nasogastric tube.
Enteral feeding bypasses the normal swallowing mechanism, significantly increasing the risk of gastric reflux and aspiration of stomach contents into the respiratory tract.
2
Determine the appropriate risk-reduction intervention.
Positioning the client with their upper body elevated is required.
An elevated position uses gravity to help keep gastric contents in the stomach, thereby preventing aspiration pneumonia, which is a severe and potentially life-threatening complication.

Key Concept

Preventing aspiration in clients receiving enteral nutrition requires continuously maintaining the upper body in an elevated position.
Estimated Time:1m 0s
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Topics

Reduction of Risk Potential

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