Examkin

Soru

Zorluk: KolayReduction of Risk Potential

An adult client is receiving scheduled enteral nutrition through a percutaneous endoscopic gastrostomy tube. Which intervention should the nurse implement to decrease the risk of aspiration?

  1. A
    Place the client in a strict flat, supine position while the formula is infusing.
  2. B
    Delegate the initial auscultation of lung sounds to an unlicensed assistive personnel.
  3. Maintain the client's upper body in a semi-Fowler's position during the administration.Cevap
  4. D
    Perform deep abdominal palpation prior to auscultating bowel sounds to evaluate tolerance.

Cevap

Maintain the client's upper body in a semi-Fowler's position during the administration.
Elevating the upper body into a semi-Fowler's position uses gravity to keep the administered formula inside the stomach, which directly decreases the likelihood of regurgitation and aspiration into the lungs.

Adım Adım Çözüm

1
Identify the primary complication associated with enteral feedings.
The most significant severe risk is aspiration of stomach contents into the respiratory tract.
Formula introduced into the stomach can reflux into the esophagus if not properly managed.
2
Determine the physiological principle that prevents this complication.
Gravity assists in keeping gastric contents in the stomach and promotes downward emptying.
Elevating the upper body prevents fluid from traveling upward toward the airway.
3
Select the nursing action that applies this principle.
Positioning the client in a semi-Fowler's position elevates the upper body appropriately.
This specific position effectively reduces the risk of aspiration during and after the feeding.

Anahtar Kavram

Aspiration Precautions for Enteral Feedings
Tahmini Süre:45s
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Konular

Reduction of Risk Potential

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