A practical nurse (PN) is providing care for a client who is receiving a continuous enteral feeding via a nasogastric (NG) tube. The client suddenly develops a severe coughing spell, becomes tachypneic, and appears highly restless.
In what order should the PN perform the following actions? Arrange the actions in sequence from first to last.
- 1Stop the continuous enteral feeding pump.
- 2Place the client in a high-Fowler's or side-lying position.
- 3Auscultate lung sounds and measure the client's oxygen saturation.
- 4Report the sudden change in condition to the registered nurse (RN).
- 5Document the clinical event, vital signs, and nursing interventions.
Answer
First, stop the enteral feeding pump. Second, place the client in a high-Fowler's or side-lying position. Third, auscultate lung sounds and measure oxygen saturation. Fourth, report the condition to the registered nurse (RN). Finally, document the event.
When a client receiving an enteral feeding exhibits signs of respiratory distress such as a severe coughing spell and tachypnea, pulmonary aspiration is the primary concern. According to the Airway, Breathing, Circulation (ABC) priority framework, the absolute first step is to remove the immediate threat to the airway by pausing the feeding pump. Next, the airway must be mechanically protected by positioning the client upright or on their side. After the airway is physically safeguarded, the PN collects targeted data (lung sounds, oxygen saturation) to assess the severity of the breathing compromise. This critical data is then rapidly communicated to the RN or provider for advanced medical interventions. Documentation is strictly performed last, once the client is safe and the broader care team is engaged.
Step-by-Step Solution
Key Concept
Prioritization of emergency interventions during suspected aspiration (Airway-Breathing-Circulation approach).