Examkin

Soru

Zorluk: KolayBasic Care and Comfort

A nurse is preparing to change the soiled bed linens for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client is currently resting comfortably in a semi-Fowler's position. Which action must the nurse take first before lowering the head of the bed to turn the client?

  1. Pause the continuous enteral feeding pump.Cevap
  2. B
    Instruct the unlicensed assistive personnel to pause the feeding pump.
  3. C
    Lower the head of the bed to a completely flat position to facilitate turning.
  4. D
    Apply soft wrist restraints to ensure the tube remains secure while turning.

Cevap

Pause the continuous enteral feeding pump.
When a client is receiving continuous enteral tube feedings, the head of the bed must remain elevated (typically 30 to 45 degrees) to prevent gastric reflux and pulmonary aspiration. Before lowering the head of the bed for any routine nursing care, such as repositioning or linen changes, the nurse must first pause the feeding pump to ensure client safety.

Adım Adım Çözüm

1
Identify the immediate risk associated with lowering the head of the bed for a client receiving continuous enteral feedings.
The primary risk is pulmonary aspiration of gastric contents if the client is placed supine while feeding is active.
Gravity helps keep enteral formula in the stomach; lowering the bed removes this protective factor.
2
Determine the necessary nursing intervention to mitigate this risk.
The nurse must stop the flow of the enteral formula.
Pausing the pump ensures no new formula enters the stomach while the client is lying flat for the linen change.

Anahtar Kavram

Aspiration Prevention during Enteral Feeding
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Konular

Basic Care and Comfort

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