A patient receiving an enteral feeding suddenly coughs, has a wet voice, and develops falling oxygen saturation. What should the nurse do first?
Correct answer: A. Stop the feeding and assess the patient's breathing
- A. Stop the feeding and assess the patient's breathing
- B. Flush the feeding tube with additional sterile water
- C. Lower the head of the bed to reduce abdominal pressure
- D. Continue the feeding while requesting a chest radiograph
Explanation
Coughing, a wet voice, and falling oxygen saturation suggest aspiration during feeding. Stopping the feed prevents further aspiration, after which the nurse assesses the airway and breathing.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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