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 C
Explanation
Choice A: Regular exercise is a good lifestyle modification, but it is not as important as smoking cessation. Exercise can help lower blood pressure, cholesterol, and weight, but it cannot reverse the damage caused by smoking.
Choice B: Stress reduction is a good lifestyle modification, but it is not as important as smoking cessation. Stress can trigger or worsen cardiac problems, but it cannot cause them as directly as smoking.
Choice C: Smoking cessation is the most important lifestyle modification because smoking is a major risk factor for cardiac disease. Smoking damages the blood vessels, increases blood pressure, reduces oxygen supply, and promotes clot formation.
Choice D: Low-fat diet is a good lifestyle modification, but it is not as important as smoking cessation. A low-fat diet can help lower cholesterol and prevent plaque buildup, but it cannot undo the effects of smoking.
Correct Answer is A
Explanation
Choice A Reason: This is correct because beginning with questions that are less sensitive in nature can help establish rapport and trust with the client, and make the client more comfortable and willing to disclose personal information.
Choice B Reason: This is incorrect because asking questions in a vague, non-specific format can confuse the client and lead to inaccurate or incomplete data. The nurse should ask clear, direct, and open-ended questions that elicit relevant information.
Choice C Reason: This is incorrect because getting the most difficult questions over with first can make the client feel anxious, embarrassed, or defensive, and discourage further communication. The nurse should build up to the more sensitive questions gradually and respectfully.
Choice D Reason: This is incorrect because sharing personal values to put the client at ease can be inappropriate and unprofessional, as it may impose the nurse's beliefs or opinions on the client or create bias or judgment. The nurse should maintain a neutral and objective attitude and respect the client's values.
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