A nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. Upon entering the room, the nurse observes the client coughing forcefully, expectorating formula, and displaying circumoral cyanosis. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)
- 1Stop the continuous enteral feeding infusion immediately.
- 2Position the client in a lateral decubitus position and suction the oropharynx.
- 3Administer supplemental oxygen to address hypoxia.
- 4Obtain a complete set of vital signs and auscultate lung sounds.
- 5Notify the primary healthcare provider of the acute event.
Answer
The correct sequence is: Stop the feeding, position and suction the airway, administer oxygen, assess vital signs and lung sounds, and then notify the healthcare provider.
In any medical emergency, the nurse must first remove the immediate source of harm and then systematically follow the ABC (Airway, Breathing, Circulation) framework. Stopping the feeding halts the aspiration source. Positioning the client laterally and suctioning clears the airway. Administering oxygen supports breathing and treats cyanosis. Only after these life-saving, stabilizing interventions are performed should the nurse conduct a full diagnostic assessment and notify the provider for further orders.
Step-by-Step Solution
Key Concept
Prioritization of nursing interventions during an acute aspiration event following the ABC (Airway, Breathing, Circulation) framework.