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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Choice A rationale
Knowing when the client voided following catheter removal is crucial because it indicates the return of the client’s ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.
Choice B rationale
The time of the last dose of IV antibiotic administration is important for managing the client’s urinary tract infection, but it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.
Choice C rationale
Intake and output reports for the previous shift are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.
Choice D rationale
The color of the urine during catheter removal may provide some insight into the client’s urinary condition, but it is not as critical as knowing when the client voided after catheter removal to assess urinary function.
Correct Answer is A
Explanation
Choice A rationale
The SBAR (Situation, Background, Assessment, Recommendation) format is specifically designed for critical communication, particularly when reporting a change in a client’s condition to the healthcare provider. This structured communication tool ensures that essential information is conveyed clearly and concisely, reducing the risk of miscommunication and enhancing patient safety.
Choice B rationale
Completing discharge teaching to a client and family members typically involves providing comprehensive instructions and education, which may not fit the concise and focused nature of the SBAR format. Discharge teaching requires a more detailed and interactive approach to ensure understanding and compliance.
Choice C rationale
Obtaining clarification from a client’s healthcare power-of-attorney involves a more conversational and detailed exchange of information, which may not align with the structured and concise nature of the SBAR format. This interaction often requires a thorough discussion to ensure all aspects are understood.
Choice D rationale
Offering therapeutic support and comfort to a grieving family is a sensitive and empathetic interaction that requires a compassionate and patient-centered approach. The SBAR format is not suitable for this type of communication, as it is designed for conveying critical information quickly and efficiently.