A client recovering from an ischemic stroke is receiving a continuous enteral tube feeding. The client suddenly develops a forceful cough, perioral cyanosis, and audible wheezing. In what order should the practical nurse (PN) perform the following actions? (Arrange the items in the correct chronological sequence from first to last.)
- 1Stop the continuous enteral feeding pump.
- 2Position the client in a high-Fowler's position.
- 3Obtain the client's oxygen saturation and vital signs.
- 4Auscultate the client's anterior and posterior lung sounds.
- 5Notify the registered nurse (RN) about the change in condition.
Answer
The correct sequence of actions is to first stop the enteral feeding, then elevate the head of the bed, obtain vital signs and oxygen saturation, auscultate lung sounds, and finally notify the RN.
In an acute respiratory emergency involving enteral feedings, the practical nurse must follow the ABCs (Airway, Breathing, Circulation) framework and the nursing process. The immediate threat is ongoing aspiration, so the feeding must be stopped first to secure the airway. Next, positioning the client upright supports breathing and ventilation. Only after these immediate interventions should the nurse gather assessment data (vital signs followed by focused auscultation) to prepare a complete clinical report. Finally, the nurse escalates the situation by notifying the RN with the collected data.
Step-by-Step Solution
Key Concept
When a client experiences sudden respiratory distress during an enteral feeding, the practical nurse must prioritize interventions using the airway, breathing, and circulation (ABC) framework: first stop the feeding (airway), optimize positioning (breathing), gather physiological data, and then escalate care.