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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 A

Explanation

Choice A rationale

Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct technique for subcutaneous heparin injections. This reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication.

Choice B rationale

Rotating injections between the abdomen and gluteal areas is not recommended for low molecular weight heparin (LMWH) injections. The abdomen is the preferred site for consistent absorption.

Choice C rationale

Massaging the injection site to increase absorption is not recommended for LMWH injections. Massaging can cause bruising and affect the absorption of the medication.

Choice D rationale

Expelling the air in the prefilled syringe prior to injection is not recommended for LMWH injections. The air bubble helps ensure the entire dose is administered and prevents medication from leaking out.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.

Choice B rationale

Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.

Choice C rationale

Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep

.

Choice D rationale

Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.

Choice E rationale

Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.

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