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Zorluk: KolayReduction of Risk Potential

A nurse is developing a plan of care for a 72-year-old client who recently suffered an ischemic stroke and is now receiving continuous enteral nutrition via a nasogastric (NG) tube. Which of the following actions should the nurse include to minimize the risk of complications? Select all that apply.

  1. Elevate the head of the bed to at least 30 degrees while the feeding is infusing.Cevap
  2. Verify tube placement by checking the pH of aspirated gastric contents.Cevap
  3. Flush the feeding tube with 30 mL of water before and after medication administration.Cevap
  4. D
    Keep the feeding infusing continuously when lowering the head of the bed to a flat, supine position for turning.
  5. E
    Delegate the initial auscultation of the client's lung sounds to the unlicensed assistive personnel (UAP).
  6. F
    Palpate the client's abdomen deeply before auscultating for bowel sounds during the daily gastrointestinal assessment.

Cevap

The correct actions to minimize complications are elevating the head of the bed, verifying tube placement with pH testing, and flushing the tube with water before and after medications.
The correct actions focus on mitigating the primary risks of enteral feeding. Elevating the head of the bed to at least 30 degrees uses gravity to prevent gastric reflux and aspiration. Verifying tube placement by checking the pH of aspirated contents ensures the formula is delivered to the stomach, not the lungs. Flushing the tube with 30 mL of water before and after medications prevents chemical interactions that could occlude the tubing.

Adım Adım Çözüm

1
Identify the primary physiological risks associated with continuous enteral feedings via a nasogastric (NG) tube.
The most significant immediate risks include pulmonary aspiration, tube occlusion, and improper tube displacement.
Understanding potential complications is essential for selecting appropriate preventive interventions.
2
Evaluate each nursing intervention against established safety protocols for enteral feedings.
Elevating the head of the bed prevents aspiration. Checking pH confirms placement. Flushing maintains patency. Conversely, pausing the feeding is required when laying the client flat. Lung assessments cannot be delegated. Abdominal assessment requires auscultation prior to palpation.
Applying standard nursing guidelines ensures safe practice and objective risk reduction.
3
Select all the appropriate evidence-based interventions.
The correct safety interventions are elevating the head of the bed, confirming placement via pH, and routinely flushing the tube.
These specific actions directly address and mitigate the identified risks of enteral feeding.

Anahtar Kavram

To reduce the risk of complications during enteral tube feedings, the nurse must implement aspiration precautions, maintain tube patency, confirm proper placement, and perform accurate, non-delegated assessments.
Tahmini Süre:1m 30s
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Reduction of Risk Potential

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