For a client with decreased LOC receiving enteral feedings, what is the priority action by the nurse?

Elevating the head of the bed 30° to 45° is crucial for a client with decreased level of consciousness who is receiving enteral feedings. This position helps to prevent aspiration, which is a significant risk for individuals with altered consciousness, as they may have impaired protective airway reflexes. When the head of the bed is elevated, gravity assists in keeping the formula in the stomach and reduces the likelihood of it backing up into the esophagus and entering the airway.

Maintaining an appropriate head position during enteral feedings can significantly decrease the risk of aspiration pneumonia, a serious complication that can arise if feedings are inhaled into the lungs. This is especially important in clients with a decreased level of consciousness as they may not be able to maintain their airway or respond adequately to potential choking or aspiration events.

Other options, while important aspects of care, do not address the immediate risk of aspiration in this scenario. Observing respiratory status is important but would not be as effective in preventing an aspiration incident. Monitoring intake and output every 8 hours helps assess the client’s nutritional needs and fluid balance, and checking residual volume helps determine gastrointestinal tolerance to feedings, but these measures do not proactively prevent aspiration when a client is at risk.