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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
To find the volume of the solution needed, the nurse can use the formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
Substituting the given values, we get:
Volume (mL) = 1 mg / 0.4 mg/mL
Simplifying, we get:
Volume (mL) = 2.5 mL
Therefore, the nurse should administer 2.5 mL of naloxone to give a dose of 1 mg.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Reason: This is correct because hospice provides comfort, dignity, and emotional support to clients with terminal illnesses and their families. Hospice focuses on palliative care rather than curative treatment.
Choice B Reason: This is correct because hospice can be provided within comforts of home or in other settings such as nursing homes or hospice facilities. Hospice allows clients to die in their preferred environment.
Choice C Reason: This is correct because hospice services can be initiated prior to discharge from the hospital or at any time during the course of the illness. Hospice requires a physician's order and a prognosis of six months or less to live.
Choice D Reason: This is correct because family members can be involved in the plan of care and receive education, counseling, and bereavement support from hospice staff. Hospice promotes family-centered care and respects cultural and spiritual preferences.
Choice E Reason: This is incorrect because a living will remains valid when receiving hospice care. A living will is a legal document that expresses the client's wishes regarding life-sustaining treatments in case of incapacity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.