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 D
Explanation
Choice A rationale
Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.
Choice B rationale
Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.
Choice C rationale
Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.
Choice D rationale
Asking the client what is causing the grimacing is the correct intervention to implement first. Nonverbal cues, such as grimacing, can indicate the presence of pain, even if the client denies it verbally. By closely monitoring the client’s nonverbal behavior, the nurse can gather additional information about the client’s pain experience and make appropriate interventions based on a comprehensive assessment.
Correct Answer is B
Explanation
Choice A rationale
Capillary refill time is 2 seconds. A capillary refill time of 2 seconds is within normal limits and is unlikely to affect the accuracy of the pulse oximetry reading.
Choice B rationale
2+ edema of fingers and hands. Edema can interfere with the accuracy of pulse oximetry readings by affecting the perfusion of the area where the sensor is placed. This can lead to falsely low oxygen saturation readings.
Choice C rationale
Radial pulse volume is 3+. A strong radial pulse indicates good peripheral perfusion, which should not negatively impact the accuracy of the pulse oximetry reading.
Choice D rationale
Blood pressure is 142/88 mm Hg. While elevated blood pressure can have various effects on the body, it is not likely to directly affect the accuracy of a pulse oximetry reading.