Editing Fundamentals of Nursing – RN Practice Questions (section)

==Question 4==
A patient receiving continuous enteral tube feeding is found lying flat in bed. What is the nurse's priority action?
# Stop the feeding and notify the provider.
# Check the gastric residual volume.
# Raise the head of the bed to at least 30 degrees.
# Auscultate the lungs for adventitious sounds.

'''Answer:''' 3. Raise the head of the bed to at least 30 degrees.

''Rationale:'' A patient lying flat during enteral feeding is at immediate risk for reflux and aspiration. The priority is to eliminate the hazard by elevating the head of the bed to at least 30 degrees, and preferably 30 to 45 degrees, and keeping it elevated for 30 to 60 minutes after the feeding. This is an emergency style situation where the required action is obvious and immediate, so it precedes further assessment. Options 2 and 4 are appropriate follow up assessments after the patient is made safe. Option 1 is premature; there is no indication yet to stop the feeding or call the provider.