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. a full pitcher of water is sitting on the clients bedside table within the clients reach.
b. the disposable feeding bag is from the previous day at 1000 and contains 200 ml of feeding.
c. the client is lying on the right side with a visible dependent loop in the feeding tube.
d. the head of the bed is elevated to 20°.

Explanation:

• Option A: A dehydrated client having access to water is appropriate, no intervention needed.
• Option B: Disposable feeding bags should be replaced every 24 hours; a bag from 1000 the previous day is within the safe window, no intervention needed.
• Option C: A dependent loop in the feeding tube can cause formula pooling and increase aspiration risk; this requires intervention.
• Option D: Elevating the head of the bed to 30-45 degrees is standard for tube feeding, but 20° is not a critical issue requiring immediate intervention compared to the dependent loop.

Answer:

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