Fundamentals of Nursing Q 94
Which of the following is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
A. Measure intake and output
B. Check albumin level
C. Monitor glucose levels
D. Increase enteral feeding
Correct Answer: A. Measure intake and output
It is important to measure intake and output, which should be equal. Water given before feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance. A urinary catheter is inserted to assess the adequacy of renal perfusion. The kidney requires 20% to 25% of cardiac output; commonly, it’s the first organ to show the effects of impaired perfusion or intravascular volume.
Option B: Osmotherapy aims to increase the osmolality of the intravascular space, which in turn helps mobilize excess fluid from brain tissue. If ICP increases, mannitol (an osmotic diuretic) may be given to decrease cerebral edema, transiently increase intravascular volume, and improve cerebral blood flow.
Option C: Low peripheral oxygen saturation values or low arterial blood oxygen values (as shown by arterial blood gas testing) should be avoided. Maintaining adequate brain tissue oxygenation seems to improve patient outcomes.
Option D: Enteral feedings are hyperosmotic agents pulling fluid from cells into the vascular bed. Initially, a nasogastric or orogastric tube is inserted to decompress the stomach and reduce the aspiration risk. (Typically, the nasal route is avoided as it can obstruct sinus drainage, leading to sinusitis or VAP).