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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?

A.

Review the advanced directive document.

B.

Irrigate the nasogastric tube with water.

C.

Elevate the head of the bed 45 degrees.

D.

Perform oropharyngeal suctioning.

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation. This approach does not address the need to document the 0900 occurrence.

Choice B rationale

Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.

Choice C rationale

Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an option, but it may not provide sufficient clarity regarding the timing of the documentation. Using a “late entry” label could potentially lead to confusion or misinterpretation.

Choice D rationale

Making an electronic addendum following the 1400 documentation is the best approach. An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It ensures accuracy and transparency in the medical record.

Correct Answer is D

Explanation

Choice A rationale

Adhering to the medication regimen is important, but it does not specifically address the client’s ability to self-administer insulin, which is crucial for managing hyperglycemia post- discharge.

Choice B rationale

Auscultating breath sounds every 4 hours is important for monitoring respiratory status but does not address the client’s need to manage their diabetes through self-injection of insulin.

Choice C rationale

Demonstrating the ability to change the ostomy bag is important for postoperative care but does not address the specific need for managing hyperglycemia through insulin self- administration.

Choice D rationale

Ensuring the client can self-administer insulin injections before discharge is crucial for managing their hyperglycemia and maintaining their health post-discharge.

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