The nurse notes that the tube-fed client has shallow breathing and dus

The nurse notes that the tube-fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What should the nurse do first?

1. Place the client in high Fowler’s position.
2. Turn off the tube feeding.
3. Assess the client’s lung sounds.
4. Assess the client’s bowel sounds.

ANSWER

Correct Answer: 2
Rationale 1: This action is not the priority.
Rationale 2: These findings indicate possible aspiration of the feeding. The priority action is to discontinue the feeding to eliminate the amount of material going into the client’s lungs. This should be done before any further assessment or client position change is attempted. If it is discovered that there is no aspiration, the tube feeding can be restarted.
Rationale 3: This is not the priority action.
Rationale 4: This is not the priority action.