The nurse is caring for a comatose client who is receiving continuous enteral nutrition through a soft nasogastric tube and notes the presence of new crackles in the client's lungs. In which order will the nurse take the following actions?
A)Turn off the tube feeding.
B)Document assessment findings.
C)Check the tube feeding residual volume.
D)Notify the client's health care provider.

Question

Quizplus · Accepted Answer

The assessment data indicate that aspiration may have occurred, and the nurse's first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the residual volume because it provides data about possible causes of aspiration. The health care provider should be notified and informed of all the assessment data the nurse has just obtained. Lastly, the nurse documents the assessment findings.

The Nurse Is Caring for a Comatose Client Who Is