A practical nurse (PN) enters the room of a client receiving a continuous enteral tube feeding. The client is coughing forcefully, appears dyspneic, and is clutching their chest. In which order should the PN perform the following actions? (Arrange the actions from first to last.)
- 1Stop the continuous enteral feeding pump.
- 2Elevate the head of the bed to a high-Fowler's position.
- 3Obtain the client's oxygen saturation and respiratory rate.
- 4Notify the registered nurse (RN) of the client's status.
- 5Gather equipment for potential oropharyngeal suctioning.
Cevap
The correct sequence is: Stop the continuous enteral feeding pump, elevate the head of the bed to a high-Fowler's position, obtain the client's oxygen saturation and respiratory rate, notify the registered nurse (RN) of the client's status, and then gather equipment for potential oropharyngeal suctioning.
In any clinical emergency, the nurse must prioritize actions using the Airway, Breathing, Circulation (ABC) framework and the nursing process. The absolute first step is to stop the continuous feeding to eliminate the immediate risk of further aspiration (Airway). Second, positioning the client in a high-Fowler's position maximizes lung expansion (Breathing). Third, the nurse assesses the client's respiratory status to gather objective data. Fourth, the nurse reports these findings to the RN for escalation of care. Finally, the nurse anticipates further needs by gathering suction equipment.
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Anahtar Kavram
Prioritization of care for suspected aspiration during enteral tube feeding