Question

a nurse is caring for a client who is dehydrated and is receiving a continuous tube feeding through a pump at 75 ml/hr. when the nurse checks the client at 0800, which of the following findings requires intervention by the nurse?

a full pitcher of water sitting on the clients bedside table within the clients reach.

the disposable feeding bag is from the previous day at 1000 and contains 200 ml of feeding

the client is lying on the right side with a visible dependent loop in the feeding tube

the head of the bed is elevated 20°

Explanation:

To determine which finding requires intervention, we analyze each option:

• Option A: A full pitcher of water within reach is appropriate for a dehydrated client to increase fluid intake, no intervention needed.
• Option B: Disposable feeding bags should be changed every 24 hours (or per facility policy). If the bag is from the previous day at 1000 and it's now 0800, it has been in use for almost 24 hours but still has 200 mL. However, the main issue here is not just timing but also potential contamination, but this is not the most critical.
• Option C: A dependent loop in the feeding tube can cause feeding to back up or slow down, but it's not as critical as incorrect bed elevation.
• Option D: For clients receiving tube feedings, the head of the bed should be elevated at least 30° to prevent aspiration. Elevating it only 20° is insufficient and increases the risk of aspiration, which is a serious complication. This requires immediate intervention.

Answer:

D. The head of the bed is elevated \( 20^\circ \)