Question

the nurse assigned to the care of an unconscious client is making initial daily rounds. on entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. the nasogastric tube feeding is running at 70 ml/hr, as prescribed. the nurse assesses the client and auscultates adventitious breath sounds. which judgment would the nurse formulate for the client?

Answer 1

Based on the given information, the nurse can make the following judgments regarding the client:

Risk of aspiration: The client being supine in bed with the head of the bed elevated at only 5 degrees may increase the risk of aspiration. To minimize this risk, the head of the bed should ideally be elevated at least 30 degrees or higher. The nurse should adjust the bed to the appropriate position to ensure safety.

Possible lung congestion: The presence of adventitious breath sounds suggests the client may have abnormal lung sounds, such as crackles or wheezes. This can indicate lung congestion or the presence of fluid in the lungs. The nurse should further assess the client's respiratory status and notify the healthcare provider if necessary.

Adequacy of nasogastric tube feeding: The prescribed rate of 70 ml/hr for the nasogastric tube feeding should be assessed to determine if it is appropriate for the client's condition and tolerance. The nurse should assess the client for any signs of intolerance to the feeding, such as abdominal distention or residual volume in the tube, and document these findings.

Step-by-step explanation:

Answer 2

The nurse would formulate the judgment that the client is comfortable and resting comfortably with the nasogastric tube feeding. The nurse would also be sure to monitor the client's vitals closely, and to notify the physician of any changes or concerning observations. Additionally, the nurse would document in the client's chart a thorough bedside assessment of comfort and signs and symptoms to monitor for any changes in the client's condition over the course of the shift.