A nurse is caring for a client who has been receiving contin… | MyMerci
Basic Care and ComfortBCC
Question
A nurse is caring for a client who has been receiving continuous enteral tube feeding for 3 days. The client suddenly develops coughing and shortness of breath. Which action should the nurse take first?
1Stop the infusion pump immediately.✓ Correct answer
2Elevate the head of the bed to 45 degrees.
3Check the gastric residual volume.
4Verify tube placement with an abdominal X-ray.
Explanation
When a client receiving enteral feeding develops sudden coughing and shortness of breath, aspiration should be suspected. The priority action is to stop the feeding immediately to prevent further aspiration. Elevating the head of the bed is a preventive measure but is not the first action when aspiration is already suspected. Checking gastric residual volume assesses tolerance but does not address the immediate risk of ongoing aspiration. Verifying tube placement with an abdominal X-ray is important but is not the most urgent intervention when the client is symptomatic.