A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins to cough forcefully and expel vomitus. In which order should the PN perform the following actions? Arrange the actions from first to last.
- 1Stop the continuous enteral feeding pump.
- 2Turn the client onto their side.
- 3Clear the client's airway using oral suctioning.
- 4Measure the client's oxygen saturation and respiratory rate.
- 5Notify the registered nurse of the client's status change.
Cevap
The correct sequence is to first stop the enteral feeding, turn the client onto their side, clear the airway using oral suctioning, measure oxygen saturation and respiratory rate, and finally notify the registered nurse.
In any acute clinical emergency, the practical nurse must prioritize actions based on the Airway, Breathing, and Circulation (ABC) framework. When a client receiving tube feedings begins to vomit, the airway is immediately threatened. The very first action must be to stop the cause (the feeding pump) to prevent more volume from entering the stomach. The second action is to use gravity to clear the airway by turning the client to the side. The third action is to use equipment (suction) to clear any remaining fluid. Once the airway is physically secured, the nurse assesses breathing (oxygen saturation, respiratory rate) to evaluate the impact of the event. Finally, the nurse communicates the findings and actions to the registered nurse.
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Anahtar Kavram
Prioritization of Airway, Breathing, and Circulation (ABC) during an acute aspiration event.
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