Examkin

Soru

Zorluk: OrtaAccident, Error, and Injury Prevention

A nurse is preparing to assist a client with a bed bath and a complete linen change. The client is currently receiving continuous enteral nutrition via a nasogastric tube. Which action is the most important for the nurse to take to prevent a severe injury or adverse event during this care?

  1. Pause the continuous enteral feeding pump before lowering the head of the bed.Cevap
  2. B
    Position the client completely flat and rapidly complete the linen change to minimize time supine.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to monitor the client for coughing or respiratory distress while turning.
  4. D
    Aspirate and measure the gastric residual volume immediately before initiating the bed bath.

Cevap

Pause the continuous enteral feeding pump before lowering the head of the bed.
Lowering the head of the bed while a continuous enteral feeding is infusing significantly increases the risk of regurgitation and aspiration of gastric contents into the lungs. Pausing the feeding before repositioning the client flat is the critical, immediate safety intervention required to prevent aspiration pneumonia, a severe and potentially life-threatening complication.

Adım Adım Çözüm

1
Identify the primary safety hazard in the scenario.
The client is receiving continuous enteral feedings, which carries a high risk of pulmonary aspiration if gastric contents reflux.
Recognizing the mechanism of potential injury is the first step in clinical prevention.
2
Determine the effect of the planned procedure on this hazard.
A bed bath and linen change require lowering the head of the bed to safely turn the client side-to-side.
Proper body mechanics and patient handling require a flat surface, which conflicts with standard enteral feeding precautions (keeping the head elevated).
3
Select the nursing intervention that eliminates or mitigates the risk.
Pausing the feeding pump stops the flow of formula, preventing the stomach from overfilling while the client is supine.
This action directly removes the source of the aspiration risk during the necessary positional change.

Anahtar Kavram

Aspiration Prevention during Enteral Feeding
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Konular

Accident, Error, and Injury Prevention

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