Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

A nurse is preparing to change the bed linens for a 78-year-old client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client must be temporarily placed in a flat, supine position to allow the nurse to safely roll them side-to-side. Which of the following actions should the nurse take?

  1. Stop the continuous enteral feeding infusion before lowering the client to a supine position.Cevap
  2. B
    Maintain the head of the bed at a 15-degree angle throughout the linen change process.
  3. C
    Delegate pausing the enteral feeding pump to the unlicensed assistive personnel (UAP) prior to repositioning.
  4. D
    Reassure the client that mild coughing when laid flat is a normal age-related change in swallowing.

Cevap

The nurse must stop the continuous enteral feeding infusion before lowering the client to a supine position.
When a client receiving continuous enteral tube feedings must be placed supine for basic care procedures such as a bed bath or linen change, the priority action is to pause the feeding pump. This is an essential safety measure to prevent the regurgitation of gastric contents and subsequent aspiration into the lungs. The feeding should remain paused until the head of the bed can be safely elevated back to at least 30 to 45 degrees.

Adım Adım Çözüm

1
Identify the client's current therapy and basic care needs.
The client is receiving continuous enteral tube feedings and requires a linen change, which necessitates lying flat.
Understanding the interaction between the medical intervention and the required care procedure highlights potential safety risks.
2
Recognize the safety risk associated with positioning during enteral feedings.
Lying flat while receiving enteral feeding significantly increases the risk of gastric reflux and pulmonary aspiration.
Standard practice dictates maintaining the head of the bed at 30 to 45 degrees during feedings.
3
Determine the necessary nursing intervention to mitigate the risk.
The feeding pump must be paused before lowering the head of the bed.
Pausing the feeding ensures no new volume is introduced into the stomach while the client is flat, protecting the airway during the basic care procedure.

Anahtar Kavram

Aspiration Prevention during Basic Care
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Konular

Basic Care and Comfort

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