While walking past a client's room, a practical nurse observes a client who is receiving continuous enteral tube feeding suddenly coughing vigorously and struggling to breathe. Which sequence of actions should the practical nurse implement? Arrange the actions in the correct order from first to last.
- 1Stop the continuous enteral feeding infusion.
- 2Elevate the head of the bed to a high Fowler's position.
- 3Obtain the client's oxygen saturation and vital signs.
- 4Notify the supervising registered nurse.
Cevap
The practical nurse should first stop the enteral feeding, followed by elevating the head of the bed, then obtaining vital signs and oxygen saturation, and finally notifying the supervising registered nurse.
According to the airway, breathing, and circulation (ABC) prioritization framework, the practical nurse must first stop the immediate threat to the airway (the continuous enteral feeding). Next, positioning the client upright facilitates breathing and lung expansion. Once the client's airway and breathing are stabilized, the nurse collects objective clinical data (vital signs and oxygen saturation) before notifying the supervising registered nurse to escalate care.
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Anahtar Kavram
Prioritization in acute respiratory compromise involves addressing the airway first (stopping the immediate threat and positioning), breathing/circulation next (data collection), and then communicating findings to the team.