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Difficulty: MediumBasic Care and Comfort

A nurse is preparing to provide a bed bath and perineal care for a client who is receiving continuous enteral nutrition via a nasogastric tube. The procedure requires lowering the head of the bed to a flat, supine position. Which of the following is the priority action for the nurse to take?

  1. Pause the continuous enteral feeding infusion pump.Answer
  2. B
    Lower the head of the bed to a flat position and immediately begin the bed bath.
  3. C
    Instruct an unlicensed assistive personnel (UAP) to perform the perineal care while the feeding continues.
  4. D
    Measure the gastric residual volume to confirm it is safe to lay the client flat.

Answer

The priority action is to pause the continuous enteral feeding infusion pump.
When a client is receiving continuous enteral feedings, the head of the bed must remain elevated to at least 30 to 45 degrees to prevent gastric reflux and pulmonary aspiration. If a nursing procedure such as a bed bath or perineal care requires the client to be laid flat, the nurse must prioritize airway safety by pausing the enteral feeding pump before lowering the head of the bed.

Step-by-Step Solution

1
Identify the client's current therapy and risks.
The client is receiving continuous enteral feeding, which places them at risk for aspiration if not positioned properly.
Recognizing aspiration risk is the first step in prioritizing safe care.
2
Determine the positioning requirement for the upcoming procedure.
A bed bath and perineal care require the head of the bed to be lowered to a flat, supine position.
Understanding the physical requirements of the nursing intervention allows the nurse to anticipate safety hazards.
3
Implement the highest-priority safety intervention.
Pause the continuous enteral feeding infusion before lowering the bed.
Pausing the feeding protects the client's airway and prevents aspiration of gastric contents while they are in a supine position.

Key Concept

Aspiration Precautions and Enteral Feeding
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Topics

Basic Care and Comfort

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