NCLEX-PN

Tube Feeding ●​ Elevate Head of Bed : Keep the head of the client's bed elevated to at least 30 degrees during and after tube feedings. This position helps prevent the reflux of feeding contents into the airways. ●​ Check Residuals : Before administering a tube feeding, check and monitor residual volume in the stomach. Elevated residuals may indicate delayed gastric emptying, increasing the risk of aspiration. ●​ Assess for Abdominal Distention : Regularly assess the abdomen for distention, which can be a sign of retained nasogastric feeding contents. Address any issues promptly to reduce the risk of aspiration. By implementing these preventive measures, healthcare providers and caregivers can reduce the risk of aspiration in individuals across the lifespan and improve overall safety and well-being. Evaluating Responses to Procedures and Treatments Nurses play a crucial role in evaluating the effectiveness of care, treatments, and procedures to ensure that client goals and expected outcomes are met. This evaluation involves collecting and analyzing a range of data, including: ●​ Subjective Data : This includes information provided by the client about their symptoms, feelings, and experiences. It offers insights into the client's perspective and can help gauge their response to interventions. ●​ Objective Data : Objective data are measurable and observable facts, such as vital signs, laboratory results, physical assessments, and the client's physical condition. These provide concrete evidence of a client's response to treatment. ●​ Primary Data : Primary data are directly obtained from the client or through firsthand observations by the nurse. They offer a clear picture of the client's condition and progress. ●​ Secondary Data : Secondary data include information from various sources, such as diagnostic test results, consultations with other healthcare professionals, and the client's medical history. These data complement primary data and provide a comprehensive view of the client's health. The evaluation process involves several key steps: ●​ Comparison to Baseline Data : Nurses compare the current data to the baseline data collected before the initiation of care, treatment, or procedures. This baseline serves as a point of reference for assessing changes and progress. ●​ Assessment of Client Goals : Nurses assess whether the client's goals and expected outcomes have been achieved. These goals are often established collaboratively between the client and the healthcare team.

479

© 2025 ACHIEVE ULTIMATE CREDIT-BY-EXAM GUIDE | NCLEX-PN ​

​

​

​

​