A 21-year-old male client with a traumatic brain injury resides in a skilled nursing facility and receives continuous feeding through a percutaneous gastrostomy tube at 65 mL/hr. He is due for his scheduled intermittent bolus feeding of formula. His Braden Scale score is 14, and he has a stage 1 pressure injury over his sacrum with intact but reddened skin. He is repositioned every 2 hours per care plan. Vital signs are temperature 37.1°C, pulse 82/min, respirations 18/min, blood pressure 118/74 mmHg, and oxygen saturation 97% on room air. The head of his bed is currently at 15 degrees. The licensed practical nurse prepares to administer the scheduled bolus feeding. Which action should the nurse take before administering the feeding?
- Raise the head of the bed to at least 30 degrees, verify tube placement, and check residual before feeding.
- Administer the feeding now and reposition the client later after the infusion is complete.
- Continue the feeding as scheduled without mentioning the sacral redness during report.
- Begin the bolus feeding immediately with the head of the bed at 15 degrees to stay on schedule.