A 68-year-old patient with a gastrostomy tube has just completed enteral feeding. As the nurse prepares to continue care, which of the following is the priority intervention immediately after feeding?

1. A

   Reposition the patient to left lateral side

2. B

   Check for abdominal distension

3. C

   Flush the tube with sterile water

4. D

   Maintain upright position

Appeared in: NORCET 9 Mains - 2025

Explanation

Listen in Hindi

• The highest priority after enteral feeding is to prevent aspiration, a potentially life-threatening complication.
• Maintaining an upright position (head of bed elevated 30-45 degrees) uses gravity to prevent gastric reflux and the entry of stomach contents into the lungs.
• This intervention directly addresses patient safety by protecting the airway, which is always the top priority in nursing care (following the ABCs: Airway, Breathing, Circulation).
• Patients should remain in this elevated position for at least 30 to 60 minutes after an intermittent feeding to allow for initial gastric emptying.

Why Other Options Were Wrong

• Option A: This position does not effectively use gravity to prevent reflux. In some cases, it might even increase the risk compared to an upright position.
• Option B: This is an assessment, not an intervention. Furthermore, it is typically performed before administering the feeding to check for tolerance and delayed gastric emptying.
• Option C: While flushing the tube is a necessary step to maintain patency and prevent clogs, it is a procedural task. Immediate patient safety (preventing aspiration) takes precedence over equipment maintenance.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Priority Nursing Interventions for Enteral Feeding in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Aspiration pneumonia is a major cause of morbidity and mortality in patients receiving enteral nutrition, especially in the elderly or those with a decreased level of consciousness.
• Nurses must be vigilant about positioning during and after feeds. This simple intervention can significantly reduce the risk of serious complications.
• What if the patient cannot tolerate an upright position due to a spinal injury? In such cases, a reverse Trendelenburg position (the entire bed is tilted with the head up) might be used, along with close monitoring for any signs of respiratory distress.

How to Approach the Question

• First, identify the core of the question: it's asking for the 'priority' action 'immediately after' an event. This signals a need to rank interventions based on patient safety.
• Analyze the options in the context of nursing priorities, specifically the ABCs (Airway, Breathing, Circulation).
• Evaluate how each option relates to patient safety. Preventing aspiration is an 'Airway' issue.
• Compare the options: Maintaining an upright position directly protects the airway. Flushing the tube is about equipment patency. Checking distension is an assessment (usually done before). Left lateral position is not optimal for preventing reflux.
• Conclude that the intervention that protects the airway (maintaining an upright position) is the highest priority over procedural tasks or assessments.

Concept Tested & Keywords

• Concept Tested: Priority Nursing Interventions for Enteral Feeding
• Stem keywords: gastrostomy tube, enteral feeding, priority intervention, immediately after
• Lead-in keywords: priority intervention
• Clinical cues: 68-year-old patient, indicating potential for increased risk of complications due to age.

Question ID

QY0iY_v8DtVi-RONiBnlMq

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 pp. 204-206, 206-208