The nurse should include which action in the plan of care for the client receiving enteral feedings? Select all that apply
A) Position head of bed in semi-Fowler's during feeding.
B) Check placement of tube before initiating feeding.
C) Maintain head of bed elevated between 30 and 45 degrees at least 30 minutes after feeding.
D) Allow at least 90 minutes for each feeding.
E) Notify primary care physician for gastric residuals of 100 to 200 cc.
Ans: B, C
Feedback:
Minimize the risk of aspiration by checking proper tube placement before initiating feedings (and at frequent intervals). The nurse can also minimize the risk of aspiration by keeping the client in Fowler's position (head of bed elevated at least 30 to 45 degrees) at all times when feedings are infusing, and for 30 minutes after completion of intermittent or continuous feeding.
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