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Zorluk: KolayBasic Care and Comfort

During morning rounds, the nurse evaluates the care plan for a client who is recovering from abdominal surgery and receiving a continuous nasogastric tube feeding. Which of the following basic care interventions should the nurse implement? (Select all that apply)

  1. Elevate the head of the bed to at least 30 degrees.Cevap
  2. Provide oral hygiene with a soft toothbrush or swabs every 2 to 4 hours.Cevap
  3. C
    Place the client in a completely flat position while they are sleeping.
  4. D
    Independently increase the feeding pump rate if the client states they are hungry.
  5. E
    Withhold reporting a mild drop in blood pressure if the client appears comfortable.
  6. Assess the skin around the nostril where the tube is secured for any signs of redness.Cevap

Cevap

The correct actions include elevating the head of the bed to at least 30 degrees, providing oral hygiene every 2 to 4 hours, and assessing the skin around the nostril for redness.
Elevating the head of the bed to at least 30 degrees uses gravity to prevent regurgitation and aspiration of the feeding formula. Because clients with nasogastric tubes often breathe through their mouths, providing frequent oral hygiene is essential to prevent drying and cracking of the mucous membranes. Assessing the skin around the nares ensures that the medical device is not causing localized pressure injuries, maintaining overall skin integrity.

Adım Adım Çözüm

1
Identify the primary safety and comfort risks associated with a continuous nasogastric tube feeding.
The main risks are pulmonary aspiration, mucosal dryness, and skin breakdown around the insertion site.
Understanding these specific risks directly guides the selection of appropriate basic care interventions.
2
Evaluate each care option against safety standards and the practical nursing scope of practice.
Elevating the head of the bed, providing regular oral care, and monitoring skin integrity are safe, within-scope actions. Laying the client flat, altering feeding rates independently, and ignoring borderline vitals are unsafe or out of scope.
Ensuring that interventions promote patient safety and remain within legal boundaries is essential for proper nursing care.

Anahtar Kavram

Basic care and comfort for clients with enteral tubes involves preventing aspiration, maintaining skin and mucosal integrity, and practicing within the legal scope.
Tahmini Süre:1m 30s
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Basic Care and Comfort

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