A -year-old client with a history of dysphagia is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly exhibits severe shortness of breath, use of accessory muscles, and a pulse oximetry reading of on room air. A stat arterial blood gas (ABG) analysis shows a pH of , PaCO of mm Hg, and HCO of mEq/L. The nurse suspects acute pulmonary aspiration. Which of the following immediate interventions should the nurse implement? Select all that apply.
- Stop the continuous enteral feeding pump.Answer
- Initiate supplemental oxygen therapy to treat hypoxemia.Answer
- CPlace the client in a flat, supine position to facilitate a comprehensive respiratory examination.
- DAdminister intravenous sodium bicarbonate to correct the underlying metabolic acidosis.
- EPalpate the client's abdomen to assess for gastric retention before evaluating bilateral breath sounds.
- FContact the healthcare provider to request a discontinuation order prior to turning off the enteral feeding.
Answer
The correct actions are to stop the continuous enteral feeding pump and initiate supplemental oxygen therapy.
The client is experiencing an acute respiratory emergency due to suspected aspiration. Immediate independent nursing actions must focus on stopping the source of aspiration by turning off the enteral feeding and treating the severe hypoxemia with supplemental oxygen. These interventions directly address the airway and breathing priorities to prevent further physiological deterioration.
Step-by-Step Solution
Key Concept
Prioritization of immediate life-saving interventions (ABCs) and correct interpretation of diagnostic data during an acute respiratory emergency to reduce the risk of physiological decompensation.