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Difficulty: HardBasic Care and Comfort

While working on a medical-surgical unit, a practical nurse evaluates an older adult client who is two days postoperative following percutaneous endoscopic gastrostomy (PEG) tube placement. The client is receiving continuous enteral nutrition. Suddenly, the individual becomes restless, complains of severe nausea, and demonstrates tachypnea. Which interventions should the practical nurse implement? Select all that apply.

  1. Stop the enteral feeding infusion pump immediately.Answer
  2. Raise the head of the bed to an angle of 45 degrees or higher.Answer
  3. Obtain a current set of vital signs and oxygen saturation levels.Answer
  4. D
    Lower the bed to a flat, horizontal position to inspect the surgical insertion site.
  5. E
    Administer a prescribed intravenous push (IVP) antiemetic medication.
  6. F
    Document the sudden restlessness as a normal, age-related response to hospitalization.

Answer

The correct actions are to stop the enteral feeding infusion pump, raise the head of the bed to 45 degrees or higher, and obtain a current set of vital signs.
The client's presentation of restlessness, nausea, and tachypnea strongly suggests aspiration, hypoxia, or feeding intolerance. The immediate nursing priorities are to protect the airway by halting the continuous enteral feeding and elevating the head of the bed to maximize chest expansion. Collecting vital signs is a safe, within-scope action that provides critical objective data for the RN or provider.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is showing sudden signs of respiratory distress (tachypnea), gastrointestinal distress (severe nausea), and hypoxia (restlessness) while receiving continuous enteral feeding.
Recognizing the combination of these symptoms indicates a high risk for aspiration or acute feeding intolerance.
2
Identify the immediate priority interventions.
The most urgent actions are related to airway protection and breathing (ABCs).
Stopping the source of potential aspiration (the feeding pump) and using gravity to protect the airway and expand the lungs (elevating the head of the bed) address the most life-threatening risks.
3
Determine appropriate data collection and scope of practice constraints.
Gathering vital signs is within the practical nurse scope and provides necessary data; administering IVP medications is out of scope.
The practical nurse must collect objective data to report to the RN while safely avoiding delegated tasks that exceed licensure bounds.

Key Concept

Prioritizing airway protection, recognizing acute status changes, and adhering to the legal scope of practice during basic care and enteral feeding management.
Estimated Time:2m 0s
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Topics

Basic Care and Comfort

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