While receiving a continuous enteral tube feeding, a client with a history of stroke suddenly begins to cough forcefully, gasp for air, and develop circumoral cyanosis. The practical nurse (PN) is present at the bedside. Arrange the following actions in the priority order the PN should perform them, from first to last.
- 1Turn off the enteral feeding pump.
- 2Position the client in a lateral (side-lying) position.
- 3Suction the client's oropharynx.
- 4Apply supplemental oxygen.
- 5Alert the registered nurse (RN) or rapid response team.
Cevap
The correct sequence is to first turn off the feeding pump, position the client laterally, suction the airway, apply oxygen, and finally alert the RN.
The correct sequence follows the ABC prioritization framework and the principle of mitigating immediate harm. Stopping the feeding immediately halts further aspiration. Positioning the client laterally uses gravity to protect the airway from further fluid entry. Suctioning clears the existing obstruction to establish patency. Oxygenation treats the resulting hypoxia once the airway is clear. Finally, notifying the RN ensures the client receives advanced assessment and ongoing medical management after the immediate crisis is stabilized.
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Anahtar Kavram
Prioritization of Airway Emergencies and Aspiration Precautions