ATI RN
RN ATI Fundamentals of Nursing Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?
Correct Answer: C
Rationale: The correct answer is C: Elevate the head of the client's bed 30° to 45°. This is the priority action because it helps prevent aspiration in a client with a decreased level of consciousness receiving enteral feedings. Elevating the head of the bed reduces the risk of regurgitation and aspiration of the feeding formula into the lungs.
Observing the client's respiratory status (
A) is important but not the priority in this scenario. Monitoring intake and output (
B) and checking residual volume (
D) are important aspects of enteral feeding management but not the priority over preventing aspiration.
In summary, elevating the head of the bed is the priority to prevent aspiration, while the other options are secondary considerations in the overall care of the client.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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