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Difficulty: HardAccident, Error, and Injury Prevention

A client is recovering on a medical-surgical unit following an ischemic stroke that resulted in severe dysphagia. The client is currently receiving continuous enteral nutrition via a nasogastric (NG) tube. A family member urgently calls the practical nurse into the room, reporting that the client is suddenly highly agitated, coughing forcefully, and attempting to pull out the feeding tube. The family member insists the nurse do something immediately to protect the tube. Which action should the nurse take first to prevent client injury?

  1. Turn off the enteral feeding pump and immediately evaluate the client's respiratory effort.Answer
  2. B
    Obtain a prescription to apply bilateral soft wrist restraints to prevent accidental tube dislodgement.
  3. C
    Administer a prescribed as-needed intravenous push sedative to rapidly control the client's agitation.
  4. D
    Apply additional securement tape to the nasogastric tube while attempting to verbally de-escalate the client.

Answer

Turn off the enteral feeding pump and immediately evaluate the client's respiratory effort.
Sudden agitation and forceful coughing in a client receiving continuous enteral feeding are classic signs of pulmonary aspiration, which is a critical airway and breathing emergency. Stopping the infusion immediately prevents further aspiration injury, prioritizing physiological ABCs (Airway, Breathing, Circulation) over behavioral management or equipment protection.

Step-by-Step Solution

1
Analyze the client's clinical presentation and the immediate environment.
The client is experiencing sudden agitation and forceful coughing while receiving continuous enteral feeding.
Identifying acute, abnormal changes in the client's condition is the first step in clinical decision-making.
2
Identify the primary safety and injury risk based on the symptoms.
The combination of dysphagia, continuous feeding, and forceful coughing indicates a high probability of pulmonary aspiration.
Aspiration is a critical airway emergency that can lead to severe injury, respiratory failure, or death.
3
Determine the priority intervention based on the ABCs (Airway, Breathing, Circulation).
Stopping the infusion directly mitigates the source of the aspiration risk, protecting the airway.
Airway protection and breathing take physiological precedence over protecting equipment or managing behavioral symptoms.

Key Concept

Prioritization of Airway and Aspiration Prevention
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Topics

Accident, Error, and Injury Prevention

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