A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

Choice A reason: A gastric residual volume of 250 mL after 2 hours of infusion is not immediately alarming. Clinical guidelines often consider residuals greater than 500 mL or consistently high volumes as concerning for delayed gastric emptying or risk of aspiration. A single residual of 250 mL should be monitored, but it does not require urgent intervention. Choice B reason: A client lying in a supine position while receiving continuous enteral feedings is at high risk for aspiration. Supine positioning allows gastric contents to reflux into the esophagus and potentially enter the airway, especially in a client with a partial laryngectomy who already has altered airway protection. The immediate intervention is to elevate the head of the bed to at least 30–45 degrees to reduce aspiration risk. This is the most urgent finding because it directly threatens airway safety. Choice C reason: If the infusion pump is turned off, the client is not receiving nutrition. While this requires correction to ensure adequate caloric intake, it is not immediately life-threatening. The nurse can restart the pump and monitor the client’s nutritional status, but this does not pose an acute danger compared to aspiration risk. Choice D reason: An undated enteral feeding bag and tubing is a safety concern because it raises the risk of bacterial contamination if the equipment has been in use beyond recommended time frames (usually 24 hours). However, this issue can be corrected by replacing the bag and tubing. It is important but not as urgent as preventing aspiration.