A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?
Review the advanced directive document.
Irrigate the nasogastric tube with water.
Elevate the head of the bed 45 degrees.
Perform oropharyngeal suctioning.
The Correct Answer is C
Choice A rationale
Reviewing the advanced directive document is not an immediate action to address the client’s choking and vomiting. The priority is to clear the airway and prevent aspiration.
Choice B rationale
Irrigating the nasogastric tube with water is not appropriate in this situation as it may worsen the choking and does not address the immediate need to clear the airway.
Choice C rationale
Elevating the head of the bed 45 degrees helps to clear the airway and reduce the risk of aspiration by using gravity to keep the stomach contents down.
Choice D rationale
Performing oropharyngeal suctioning may stimulate gagging and vomiting, which can exacerbate the choking.
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Correct Answer is C
Explanation
Choice A rationale
Telling the client to dress the right arm first is practical advice but does not address the client’s frustration and emotional state. It is important to acknowledge the client’s feelings to provide empathetic care.
Choice B rationale
Offering a class on dressing tomorrow does not address the immediate frustration and emotional response of the client. The client needs support and understanding in the moment.
Choice C rationale
Acknowledging that dressing must be a frustrating experience for the client shows empathy and understanding. It validates the client’s feelings and helps build a therapeutic relationship.
Choice D rationale
Mentioning a policy against staff harassment is inappropriate and does not address the client’s frustration. It may escalate the situation and damage the nurse-client relationship.
Correct Answer is C
Explanation
Choice A rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. However, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.
Choice B rationale
Lifting and locking the side rails in place ensures the safety of the client but does not directly address the client’s OSA or the potential respiratory depression associated with opioid analgesic administration.
Choice C rationale
Applying the client’s positive airway pressure device is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.
Choice D rationale
Removing dentures or other oral appliances may be necessary for client comfort and safety, but it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.