Question

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. Auscultate bowel sounds and slow the feeding down.
B. Remove the tube immediately and notify the heath care provider.
C. Auscultate lung sounds and obtain oxygen saturation.
D. Add blue dye to the feeding tube formula.

Answer 1

The nurse's top priority is to auscultate lung sounds and obtain oxygen saturation to assess if the client's respiratory function is compromised.

Step-by-step explanation:

The nurse's top priority in this situation would be to auscultate lung sounds and obtain oxygen saturation. The vital signs provided indicate an elevated pulse rate and an increased body temperature, which could suggest an infection or inflammation. The presence of crackling lung sounds and shortness of breath is concerning for respiratory distress, which could be caused by pneumonia or another lung condition. Therefore, it is essential for the nurse to assess the lung sounds and oxygen saturation to determine if the client's respiratory function is compromised.