A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg
Which action by the nurse takes priority? a. Remove the tube immediately and notify the heath care provider.
b. Auscultate lung sounds and obtain oxygen saturation.
c. Add blue dye to the feeding tube formula.
d. Auscultate bowel sounds and slow the feeding down.
B
The client may have aspirated. The nurse should further assess the client's respiratory and oxy-genation status. The client may have another reason for the abnormal vital signs, so the nurse should not pull out the tube before performing other assessments. Adding blue dye to the tube feeding formula is not recommended to check for aspiration. Slowing the feeding down will not be helpful.
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