Editing Nursing Skills and Procedures – RN Practice Questions (section)

==Question 4==
A registered nurse receives report on four clients. Which client should the nurse assess '''first'''?
# A client with a nasogastric feeding running who is coughing and whose oxygen saturation has fallen from 96 to 88 percent.
# A client with a stage 3 pressure injury whose dressing has serosanguineous drainage.
# A client with a new peripherally inserted central catheter awaiting confirmatory chest radiograph.
# A client one day after abdominal surgery reporting incisional pain rated 6 out of 10.

'''Answer:''' 1 (A). The client with tube feeding, coughing, and falling saturation.

''Rationale:'' Coughing with acute desaturation during enteral feeding indicates probable aspiration, an airway and breathing emergency. The nurse stops the feeding, positions the client on the side, suctions, and oxygenates. Option 2 describes expected drainage from a granulating wound. Option 3 is a client awaiting a routine verification with no reported symptoms. Option 4 is an expected postoperative finding requiring analgesia but not before an airway threat.