A 32-year-old woman recovering from a traumatic brain injury is on the rehabilitation unit with a percutaneous gastrostomy tube placed 3 weeks ago for nutrition support. Her continuous feeding order is 65 mL/hr of a standard formula. Braden score is 14, and the LPN notes a reddened area over her sacrum that blanches with pressure; skin is intact but slightly moist. Vital signs: temperature 37.4°C, heart rate 88/min, respirations 18/min, blood pressure 118/72 mmHg. The head of the bed is currently at 15 degrees, and the client has been lying supine for several hours. It is time for the scheduled feeding assessment and the client's turning schedule. Which action should the nurse take first?
- Independently change the client's feeding rate and activity order based on the skin finding.
- Continue the feeding as ordered and document the sacral redness for the next shift to address.
- Begin the scheduled feeding now and reposition the client after the infusion finishes.
- Verify gastrostomy tube placement and residual, then elevate the head of bed before continuing the feeding.