A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply. A)Assess abdominal distension every 4 hours B)Check gastric residual every 12 hours C)Keep head of the bed at ≥30 degrees D)Maintain endotracheal cuff pressure E)Use caution when administering sedatives

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Quizplus · Accepted Answer

Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include: Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option A)Assess feeding tube placement at regular intervalsKeep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option C)Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H₂0) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option D)Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessaryUse caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option E)Avoid bolus tube feedings for clients at high risk for aspiration Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option A) Assess feeding tube placement at regular intervals Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option C) Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H₂0) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option D) Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option E) Avoid bolus tube feedings for clients at high risk for aspiration (Option B) Gastric residual should be checked no less than every 4 hours in intubated clients. Educational objective: Precautions to prevent aspiration in the client receiving continuous tube feedings include assessing for gastric intolerance (ie, residual, distension) every 4 hours, keeping the head of the bed at ≥30 degrees, using sedation cautiously, and regular assessment of tube placement. If the client is intubated, the nurse should also keep the endotracheal tube cuff inflated and suction appropriately.

A Client Who Is Intubated and on Mechanical Ventilation Is