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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

Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.

Choice B rationale

Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.

Choice C rationale

Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.

Choice D rationale

Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.

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.

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