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    Ati med surg proctored examQuestion 21
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    Ati med surg proctored exam

    A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next?

    Explanation & Rationale

    A. Prepare to initiate antibiotic therapy: Antibiotics may be necessary if aspiration pneumonia develops, but this is not an immediate nursing action. Medication initiation requires provider evaluation and a prescription, making this a delayed intervention. B. Obtain a prescription for a chest x-ray: A chest x-ray may be ordered to confirm aspiration, but requesting this is not the nurse’s next priority. Immediate nursing interventions to protect the airway and prevent further complications must occur first. C. Position the client on their side: Placing the client on their side helps prevent further aspiration and promotes drainage of secretions or feeding material from the airway. This is the safest immediate response after stopping the feeding. D. Suction the client's orotracheal airway: Suctioning is appropriate if the client has visible secretions, is coughing ineffectively, or shows respiratory distress. However, the priority immediate action is to position the client to reduce aspiration risk before suctioning if needed.

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