A practical nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly begins coughing vigorously, becomes tachypneic, and appears cyanotic. Arrange the following nursing actions in the correct priority order to reduce the client's risk for further complications. (Place the first action at the top and the last action at the bottom.)
- 1Stop the continuous enteral feeding.
- 2Turn the client to a lateral side-lying position.
- 3Auscultate lung sounds and measure oxygen saturation.
- 4Notify the supervising Registered Nurse (RN).
Cevap
The correct priority sequence is to first stop the continuous enteral feeding, then turn the client to a lateral side-lying position, next auscultate lung sounds and measure oxygen saturation, and finally notify the supervising Registered Nurse (RN).
When a client exhibits sudden respiratory distress during an enteral feeding, active aspiration is highly suspected. The sequence of actions follows the principle of neutralizing the immediate threat first. The nurse must stop the pump to prevent further aspiration. Next, repositioning the client laterally protects the airway and facilitates drainage. Only after these immediate physical safeguards are in place should the nurse obtain focused assessment data (vital signs, lung sounds) to accurately report the client's condition to the supervising RN for further medical orders.
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Anahtar Kavram
In emergency situations such as active aspiration, the practical nurse must prioritize immediate independent interventions that remove the risk (stopping feeding) and protect the airway (positioning) before collecting assessment data or notifying the healthcare team.