An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway?

An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway?

• A. Discontinue G-tube feeding
• B. Initiate seizure precautions
• C. Administer oxygen
• D. Obtain blood work for troponin level

Answer: (B)

The main idea is ensuring safety for a patient with acute behavioral changes and the possibility of a seizure while tests are being done. When altered mental status could be due to a seizure or could precipitate one, the priority is to prevent injury and protect the airway.

Initiating seizure precautions is the best step because a seizure can occur unexpectedly and lead to falls, head injury, or aspiration, especially in a bed-bound, tube-fed patient. Keeping the patient safe means padding or securing the environment, keeping a side-lying position to maintain the airway, having suction ready, and ensuring oxygen is available. An IV line and quick access to medications if a seizure occurs are also part of being prepared.

Discontinuing G-tube feeding isn’t the immediate action, since the underlying cause of the behavioral changes must be identified, and stopping feeding could worsen nutrition or electrolyte balance. Administering oxygen is important if there's evidence of hypoxemia, but you don’t wait for that to initiate safety measures. Obtaining troponin is not the top priority in this neuro-focused scenario, though cardiac issues can contribute to confusion; the first goal is preventing harm from a possible seizure while the workup proceeds.