A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins to cough severely, becomes dyspneic, and exhibits circumoral cyanosis. Arrange the following nursing actions in the correct order of priority.
- 1Stop the continuous enteral feeding pump.
- 2Elevate the head of the bed to a high-Fowler's position.
- 3Auscultate the client's lung sounds and obtain oxygen saturation.
- 4Notify the registered nurse (RN) of the acute change in condition.
- 5Document the respiratory event and the interventions performed.
Answer
The correct priority sequence is to first stop the feeding pump, then elevate the head of the bed, auscultate lung sounds, notify the RN, and finally document the event.
In any acute physiological crisis, the nursing process dictates prioritizing actions that eliminate the immediate threat to life (Airway, Breathing, Circulation). For suspected aspiration, stopping the feeding pump directly halts the threat. Positioning the client upright is the next immediate physical intervention to support the airway and breathing. Once these rapid physical interventions are complete, the nurse collects focused assessment data (lung sounds, oxygen saturation) to understand the severity of the event. This data is then reported to the RN to coordinate further care. Documentation is always the final administrative step in the nursing process.
Step-by-Step Solution
Key Concept
Prioritization of Care During Acute Enteral Feeding Aspiration