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Zorluk: OrtaReduction of Risk Potential

A 68-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) and a recent right-sided ischemic stroke is receiving continuous enteral tube feedings. The client suddenly develops severe dyspnea, coarse crackles in the bilateral lung bases, and an oxygen saturation of 84% on room air. To mitigate the risk of further physiological decompensation, which action is the priority for the nurse to perform?

  1. Immediately stop the continuous enteral feeding infusion and prepare to suction the airway.Cevap
  2. B
    Lower the head of the bed to a flat, left lateral decubitus position to facilitate passive drainage of secretions.
  3. C
    Administer prescribed intravenous sodium bicarbonate to correct the anticipated uncompensated respiratory acidosis.
  4. D
    Palpate and percuss the abdomen to assess for delayed gastric emptying before intervening with the airway.

Cevap

Immediately stop the continuous enteral feeding infusion and prepare to suction the airway.
Stopping the enteral feeding is the immediate priority because the clinical presentation (sudden dyspnea, coarse crackles, hypoxia) strongly indicates active aspiration of the feeding formula. The client's history of a right-sided stroke increases dysphagia and aspiration risk. Halting the infusion immediately prevents further aspiration, and suctioning clears the airway to restore oxygenation.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and risk factors.
The client has sudden dyspnea, coarse crackles, and hypoxia, combined with high risk factors (recent stroke causing potential dysphagia, and continuous tube feeding).
To identify the underlying physiological emergency, which is acute aspiration of the enteral formula.
2
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation) framework.
Airway clearance is identified as the immediate, life-saving priority over other assessments or metabolic interventions.
Failure to secure the airway will lead to rapid respiratory failure and potential cardiac arrest.
3
Determine the specific mechanical intervention required.
Stopping the feeding pump prevents further fluid from entering the lungs, and preparing suction equipment allows for immediate clearing of the aspirated contents.
Removing the source of aspiration directly mitigates the risk of further physiological decompensation.

Anahtar Kavram

Prioritization in Aspiration and Airway Management
Tahmini Süre:1m 0s
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Konular

Reduction of Risk Potential

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