A registered nurse is precepting a new nurse in the intensive care unit. The client is sedated with propofol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube. The new nurse performs interventions to prevent aspiration. The preceptor should intervene if the new nurse performs which of the following actions?

Question

A registered nurse is precepting a new nurse in the intensive care unit.  The client is sedated with propofol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube.  The new nurse performs interventions to prevent aspiration.  The preceptor should intervene if the new nurse performs which of the following actions?

Quizplus · Accepted Answer

Critically ill clients are at increased risk for aspiration of oropharyngeal secretions and gastric content. It is common in clients who are intubated, sedated, on a mechanical ventilator, and receiving enteral feedings. The nurse must provide nursing interventions to prevent aspiration and monitor for its signs and symptoms. Clients are at increased risk when receiving bolus rather than continual enteral feedings. Bolus feedings should be avoided in critically ill clients, who are already at increased risk for aspiration. (Option A) Assessing gastric residual volumes according to institution policy (at least every 4 hours) is standard for clients receiving continual enteral feedings. Increased volumes may indicate poor absorption and increase the risk of regurgitation and aspiration. (Option B) Measuring the number of centimeters at the nare every 4 hours can help determine if the tube has moved, but it can increase aspiration risk. X-ray confirmation may be necessary if the tube has moved. (Option D) A sedation scale such as the Ramsay Scale is used to assess level of sedation. It is preferable to keep the client minimally sedated (asleep but arousable). This helps decrease the risk of aspiration. Educational objective: Assessing gastric residual volumes and level of sedation at regular intervals, checking enteral feeding tube placement, and administering continual rather than bolus tube feeding are interventions that help prevent aspiration in critically ill high-risk clients.

A Registered Nurse Is Precepting a New Nurse in the Intensive