Question

A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

A. Temperature 38.2° C (100.8° F) Rationale:A fever can indicate an infection. Therefore, the priority finding to report is the client's
Temperature.
B. Respiratory rate 12/min Rationale: A respiratory rate of 12/min is within the expected reference range for an adult client.
C. Hematocrit 45% Rationale: A hematocrit level of 45% is within the expected reference range.
D. Urine specific gravity 1.015 Rationale: A urine specific gravity of 1.015 is within the expected reference range.

Answer 1

The nurse should identify the finding of a temperature of 38.2° C (100.8° F) as the priority in monitoring a client receiving tube feeding due to its potential indication of infection.

Step-by-step explanation:

The nurse should identify the finding of a temperature of 38.2° C (100.8° F) as the priority in monitoring a client who is receiving a tube feeding. A fever can indicate an infection, which can be a serious complication in a client receiving tube feeding, as it can lead to sepsis or other systemic infections. The nurse should report this finding promptly to the healthcare provider for further evaluation and intervention.