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Soru

Zorluk: KolayReduction of Risk Potential

A nurse is caring for a client who is receiving continuous enteral tube feedings via a nasogastric (NG) tube. Which actions should the nurse take to reduce the client's risk of aspiration? Select all that apply.

  1. Elevate the head of the bed to at least 30 degrees during the feeding.Cevap
  2. Pause the continuous feeding pump before lowering the head of the bed to turn the client.Cevap
  3. Assess gastric residual volumes every 4 to 6 hours as prescribed.Cevap
  4. D
    Position the client flat in a supine position for 30 minutes after medication administration.
  5. E
    Inject air into the tube and auscultate the epigastrium to confirm tube placement.

Cevap

The nurse should elevate the head of the bed to at least 30 degrees, pause the feeding pump before lowering the head of the bed, and assess gastric residual volumes every 4 to 6 hours.
Reducing the risk of aspiration requires keeping the head of the bed elevated to at least 30 degrees, pausing the feeding whenever the client must be laid flat, and regularly monitoring gastric residual volumes to detect delayed emptying.

Adım Adım Çözüm

1
Identify the primary risk associated with enteral tube feedings.
The most significant and potentially life-threatening risk is pulmonary aspiration of gastric contents.
Understanding the primary risk guides the selection of preventive nursing interventions.
2
Evaluate each option for its effect on aspiration risk.
Keeping the head elevated, pausing feedings when flat, and checking residuals actively prevent gastric reflux. Supine positioning and unreliable placement checks increase the risk.
Applying physiological principles of gravity and current evidence-based assessment standards ensures safe client care.

Anahtar Kavram

Aspiration Prevention in Enteral Feedings
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Konular

Reduction of Risk Potential

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