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?

Irrigate the nasogastric tube with water.

Review the advance directive document.

Elevate the head of bed 45 degrees.

Perform oropharyngeal suctioning.

Answer and Explanation

The Correct Answer is D

The correct answer is: d. Perform oropharyngeal suctioning.

Choice A: Irrigate the nasogastric tube with water

Reason: Irrigating the nasogastric tube with water is not appropriate when a client is choking and vomiting. This action could potentially worsen the situation by introducing more fluid into the stomach, increasing the risk of aspiration.

Choice B: Review the advance directive document

Reason: Reviewing the advance directive document is not an immediate action to take when a client is choking. Advance directives provide guidance on the client’s wishes for medical treatment but do not address acute emergency interventions.

Choice C: Elevate the head of bed 45 degrees

Reason: Elevating the head of the bed to 45 degrees can help reduce the risk of aspiration by using gravity to keep stomach contents down. However, this action alone is not sufficient to address the immediate choking hazard.

Choice D: Perform oropharyngeal suctioning

Reason: Performing oropharyngeal suctioning is the correct action because it directly addresses the choking hazard by clearing the airway of vomit and other obstructions. This is a critical step to ensure the client’s airway is clear and they can breathe properly.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because this response invites the client to express her feelings and thoughts without imposing any assumptions or judgments. It also conveys empathy and respect for the client's autonomy.

Choice B Reason: This is incorrect because this response makes an inference about the client's emotional state without validating it with her. It also may sound patronizing or pitying, which can hinder rapport.

Choice C Reason: This is incorrect because this response may be perceived as intrusive or prying, especially if the client is not ready or willing to share details about her personal relationship. It also may trigger negative emotions or memories that can worsen her mood.

Choice D Reason: This is incorrect because this response may be seen as superficial or irrelevant, especially if the client did not enjoy her visit or had a conflict with her significant other. It also may imply that the nurse is avoiding or dismissing the client's current feelings.

A. Wait to obtain the specimen until observable blood is present. B. Withhold specimen collection until tarry black stool is observed. C. Obtain the specimen from the client's current bowel movement. D. Contact the healthcare provider before obtaining the specimen.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.

Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.

Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.

Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

Correct Answer is A

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is C

Explanation

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