A patient with acute lung injury is being started on enteral nutrition
Which interventions will the nurse provide to ensure nutritional support for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Withhold the use of the nasogastric tube until radiographic placement is confirmed.
2. Monitor for diarrhea.
3. Assess for gastric residual.
4. Keep the head of the bed elevated to at least 30 degrees.
5. Ensure the tube feeding continues uninterrupted.
1,2,3,4
Rationale 1: Radiography is the gold standard to confirm placement of a nasogastric tube.
Rationale 2: Monitoring for diarrhea is assessing the patient for tolerance of the tube feeding.
Rationale 3: Assess for gastric residual is done when monitoring the patient for tolerance of the tube feeding.
Rationale 4: Keeping the head of the bed elevated to at least 30 degrees reduces the risk of aspiration of tube feeding contents.
Rationale 5: The tube feeding should be discontinued when suctioning, turning, and during extubation.
You might also like to view...
When preparing the patient for an abdominal scan, the nurse should:
a. assess labs only for liver function. b. assess patient for allergies to dye or shellfish. c. instruct patient to limit fluid intake immediately following procedure. d. instruct patient to be NPO for 1 hour before scan if contrast medium is used.
A nurse manager overhears two staff nurses talking about a third nurse, who has the day off. The nurses are making unflattering comments regarding the nurse in front of several other nurses who work on the unit
The nurse manager discretely asks to speak to the nurses' in private and states, "This behavior isn't OK, especially in a hospital like ours with a 'zero-tolerance policy.' If you have an issue with this nurse please deal with that nurse directly. If you'd like me to help you with this, please let me know, and the four of us can meet." The nurse manager's behavior modeled strategies for which type of work-place conflict? A) Stress B) Sexual harassment C) Horizontal violence D) Intrapersonal conflict
What is the priority nursing diagnosis for the older adult client who has very thin skin on the backs of the hands and arms?
A. Risk for Injury B. Risk for Infection C. Risk for Disuse Syndrome D. Risk for Imbalanced Body Temperature: hyperthermia
The client in skeletal traction for a fractured pelvis needs to use the bedpan. Which should the nurse use to prevent complications?
1. Logroll client and maintain skeletal traction. 2. Instruct client to pull up on trapeze to lift hips. 3. Remove weights on the traction and turn client. 4. Warm a metal bedpan before placing under client.