A practical nurse enters the room of a client receiving a continuous enteral tube feeding and observes the client coughing vigorously and exhibiting sudden tachypnea. In which order should the practical nurse perform the following actions? Arrange the steps from first to last.
- 1Stop the continuous enteral tube feeding.
- 2Elevate the head of the bed to a high-Fowler's position.
- 3Measure the client's oxygen saturation and respiratory rate.
- 4Report the findings to the supervising registered nurse.
- 5Document the respiratory event and the client's response.
Answer
The correct sequence is to first stop the continuous enteral tube feeding, elevate the head of the bed to a high-Fowler's position, measure the client's oxygen saturation and respiratory rate, report the findings to the supervising registered nurse, and finally document the respiratory event and the client's response.
In any emergency situation involving a continuous infusion or feeding where a severe complication is suspected, the first priority is to stop the source of potential harm. Next, the airway and breathing must be supported through proper positioning. Only after these immediate, risk-reducing interventions are completed should the nurse gather objective assessment data (vital signs) to report to the supervising registered nurse. Documentation is performed last once the client is stabilized and the healthcare team has been notified.
Step-by-Step Solution
Key Concept
Prioritization and Risk Reduction in Suspected Aspiration