The nurse assesses the client who receives continuous enteral nutrition by a nasointestinal tube. Which is the priority intervention for the nurse to implement if the client's bowel sounds are in-audible?
1. Document "absent bowel sounds.".
2. Decrease the rate of the tube feeding.
3. Observe client for altered elimination.
4. Stop the feeding and notify provider.
4
4. The nurse stops the tube feeding and collaborates with the provider after assessing a client who receives a continuous tube feeding with no evidence of peristalsis; without peristalsis, the formula accumulates in the stomach and eventually the client can vomit, increasing the risk of aspiration.
1. The nurse should document the bowel sounds are inaudible because the nurse cannot attest to the absence of peristalsis but relies on clinical indicators consistent with decreased peristalsis.
2. The nurse stops the formula because any additional formula heightens the risk of aspiration.
3. Any client receiving tube feedings receives nursing assessments for diarrhea and constipation; besides, if the client has diarrhea, bowel sounds are likely to be loud, frequent, and high-pitched.
You might also like to view...
A nurse is assisting with a female genitalia examination. The nurse will assist the patient to which position?
a. Supine b. Lithotomy c. Knee-chest d. Dorsal recumbent
The nurse assesses the client after applying skeletal traction to the head of the femur. Which clinical finding is inconsistent with the client's baseline data but acceptable to the nurse?
1. Decreased sensation in the affected foot 2. Heightened client anxiety after procedure 3. Lower leg pallor, weak pulse, and cool skin 4. Minimal bloody drainage from the pin sites
Which is the obese postpartum client at a greater risk for experiencing? Select all that apply
1. Injury 2. Infection 3. Breast engorgement 4. Deep vein thrombosis 5. Respiratory complications
Calculate the amount to administer: ________. Ordered: TriCor 144 mg PO dailyOn hand: TriCor 48 mg tablets
Fill in the blank(s) with the appropriate word(s).