A practical nurse (PN) is observing a client who is receiving continuous enteral tube feedings. The client suddenly begins coughing forcefully and appears dyspneic. Arrange the following nursing actions in the priority order the PN should perform them.
- 1Stop the continuous enteral feeding pump.
- 2Position the client on their side or in high Fowler's position.
- 3Check the client's oxygen saturation level and count the respiratory rate.
- 4Notify the registered nurse (RN).
Answer
The correct sequence is to first stop the feeding, then position the client, check respiratory status, and finally notify the RN.
In any acute respiratory event during a continuous feeding, the immediate priority is to stop the feeding to prevent further aspiration. Next, the airway must be protected by positioning the client appropriately. Once the immediate threat is mitigated, the nurse gathers data on the client's respiratory status to determine the severity of the event. Finally, the nurse reports the findings and actions to the RN.
Step-by-Step Solution
Key Concept
Airway and breathing prioritization during continuous enteral feeding complications