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Difficulty: HardReduction of Risk Potential

A client receiving continuous enteral nutrition via a nasogastric tube suddenly experiences a severe bout of coughing accompanied by tachypnea and audible airway gurgling. To effectively reduce the risk of aspiration pneumonia and stabilize the client, arrange the following nursing actions in the correct priority sequence.

  1. 1Turn off the enteral feeding pump immediately.
  2. 2Assist the client into a high Fowler's or side-lying position.
  3. 3Assess the client's respiratory rate, lung sounds, and oxygen saturation.
  4. 4Report the acute change in respiratory status to the supervising registered nurse.
  5. 5Document the clinical event, the assessment findings, and the nursing actions taken.

Answer

The correct sequence prioritizes immediate risk mitigation by stopping the pump and protecting the airway with positioning, followed by gathering assessment data, escalating to the registered nurse, and finally documenting the event.
This sequence adheres to the Airway, Breathing, Circulation (ABC) priority framework and the nursing process. Turning off the pump immediately removes the aspiration hazard. Positioning the client utilizes gravity to further protect the airway. Assessing vital signs provides essential objective data for the subsequent escalation to the registered nurse. Documentation finalizes the process once the client is stabilized and safe.

Step-by-Step Solution

1
Identify the immediate threat and turn off the enteral feeding pump.
The flow of enteral formula is halted.
Risk mitigation requires immediate cessation of the offending agent to prevent further aspiration.
2
Position the client upright in a high Fowler's position or on their side.
The airway is protected using gravity.
This prevents pooling of fluids in the pharynx and maximizes lung expansion.
3
Assess vital signs, lung sounds, and oxygen saturation.
Objective data regarding the respiratory compromise is gathered.
Accurate assessment dictates the urgency and type of further medical interventions required.
4
Report the clinical findings to the supervising registered nurse.
The healthcare team is alerted to the acute change in condition.
The practical nurse must escalate critical findings that require advanced orders, such as suctioning or imaging.
5
Document the event and all nursing actions taken.
A permanent legal record of the emergency is created.
Documentation finalizes the nursing process only after the client has been safely stabilized.

Key Concept

Airway protection and prioritization of risk mitigation during a suspected aspiration event.
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Topics

Reduction of Risk Potential

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