A practical nurse (PN) enters a client's room and observes the client coughing forcefully and clutching their chest. The client is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client appears cyanotic around the lips, and the pulse oximeter reads 86% on room air. In what order should the PN perform the following actions? (Arrange the actions from first to last.)
- 1Turn off the continuous enteral feeding pump.
- 2Elevate the head of the bed to a high-Fowler's position.
- 3Apply supplemental oxygen per facility emergency protocol.
- 4Auscultate the client's bilateral lung sounds.
- 5Notify the supervising registered nurse (RN) of the status change.
Cevap
The correct sequence is: Turn off the continuous enteral feeding pump, Elevate the head of the bed to a high-Fowler's position, Apply supplemental oxygen, Auscultate the client's bilateral lung sounds, and Notify the supervising registered nurse (RN).
In any acute respiratory emergency involving enteral feeding, the first step is to remove the noxious stimulus by stopping the pump to prevent further aspiration. Following the ABCs (Airway, Breathing, Circulation), the nurse should then position the client to maximize lung expansion and apply oxygen to treat the hypoxia. Once these immediate life-saving measures are applied, the PN should collect focused data (lung sounds) so that a complete and accurate report can be given when notifying the supervising RN.
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Anahtar Kavram
Prioritization of care during an acute aspiration event focuses on airway protection first (stopping the cause), followed by breathing support (positioning and oxygen), data collection, and then escalation.