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Soru

Zorluk: OrtaBasic Care and Comfort

A nurse is managing the care of an older adult client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client has become restless and requires a linen change as well as a sacral skin assessment. Which of the following nursing actions is most appropriate?

  1. Pause the enteral feeding pump before lowering the head of the bed to reposition the client.Cevap
  2. B
    Lower the head of the bed to a flat supine position while the feeding infuses to minimize the time spent turning.
  3. C
    Delegate the sacral skin assessment and the linen change to the unlicensed assistive personnel (UAP).
  4. D
    Apply bilateral soft wrist restraints immediately to prevent the restless client from pulling out the NG tube.

Cevap

Pause the enteral feeding pump before lowering the head of the bed to reposition the client.
The correct action is to pause the feeding pump before lowering the head of the bed. Clients receiving enteral tube feedings are at a continuous, high risk for aspiration. Standard basic care requires maintaining the head of the bed at an elevation of 30 to 45 degrees while the feeding is infusing. If the client must be laid flat to facilitate turning for a linen change or skin assessment, the feeding must be paused first to protect the airway and prevent gastric reflux.

Adım Adım Çözüm

1
Identify the client's current therapies and associated risks.
The client is receiving continuous enteral feeding via an NG tube.
Enteral feeding introduces a high risk for aspiration if the client is not positioned correctly.
2
Evaluate the physical requirements of the upcoming nursing interventions.
A linen change and sacral skin assessment require the client to be turned, which typically necessitates lowering the head of the bed.
Turning a client safely often requires a flat, side-lying position.
3
Determine the necessary safety precautions before altering the client's position.
The continuous feeding must be temporarily stopped.
Lowering the head of the bed while formula is actively infusing allows gastric contents to reflux, potentially leading to aspiration pneumonia.
4
Analyze the remaining options for scope of practice and safety policy violations.
Delegating an assessment is outside the UAP's scope, and immediately applying restraints violates the standard of using the least restrictive measures first.
Ensuring safe, legal nursing practice involves proper delegation and adherence to restraint protocols.

Anahtar Kavram

Aspiration Prevention during Enteral Feeding
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Konular

Basic Care and Comfort

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