Basic Care and Comfort NCLEX PN Questions Nursing Practice Question
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
Correct Answer: A
Rationale: Measuring intake and output is crucial for clients receiving bolus enteral feeding, especially those with major head trauma, as it helps assess hydration status, nutritional needs, and potential complications like fluid overload.
Checking albumin levels (B) is important for assessing nutritional status but is not as immediate as monitoring intake and output. Monitoring glucose levels (C) is relevant for clients with diabetes or those on certain medications, but it’s not the primary concern in this context. Increasing enteral feeding (D) without proper assessment may lead to overfeeding or gastrointestinal complications, making careful monitoring essential before any adjustments.