While rounding on a clinical unit, a practical nurse discovers a client with a continuous nasogastric tube feeding who has suddenly started coughing vigorously and expelling liquid formula from the mouth. The client is visibly struggling to breathe. Drag and drop the following nursing actions into the correct priority sequence from first to last.
- 1Halt the operation of the enteral feeding pump.
- 2Assist the client into a lateral decubitus position.
- 3Clear the upper airway using oropharyngeal suctioning.
- 4Assess the client's vital signs and pulse oximetry.
- 5Report the acute event to the supervising charge nurse.
Cevap
The correct sequence is to halt the feeding pump, turn the client to a lateral position, suction the airway, assess vital signs, and report the event to the charge nurse.
According to the ABC (Airway, Breathing, Circulation) priority framework, the immediate focus during an active aspiration event is to remove the source of the problem and protect the airway. Halting the feeding pump stops additional formula from entering the lungs. Turning the client to a lateral decubitus position uses gravity to drain emesis and prevent further aspiration of stomach contents. Clearing the upper airway with oropharyngeal suctioning removes any residual fluid that could be inhaled. Once the airway is stabilized and the immediate life threat is resolved, assessing vital signs and pulse oximetry provides critical data about the client's physiological adaptation. Finally, the practical nurse must report the acute event and the gathered assessment data to the supervising charge nurse or registered nurse for further medical evaluation.
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Anahtar Kavram
Prioritization of airway management and aspiration precautions during an acute emergency.