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 the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. This indicates that the cuff was not inflated high enough to occlude the arterial blood flow and the initial systolic reading was inaccurate. The nurse should release the air, wait for 15 to 30 seconds, and then reinflate the cuff to 30 mm Hg above the first systolic sound. This will ensure a more accurate measurement of the blood pressure.

Choice B reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Continuing the blood pressure assessment until the last Korotkoff sound is heard will result in a lower systolic reading and a higher diastolic reading than the actual blood pressure of the client. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice C reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point will not change the fact that the cuff was not inflated high enough to occlude the arterial blood flow. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice D reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound will cause discomfort and pain to the client and may damage the blood vessels. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

A. To ambulate without discomfort. B. To avoid pain-causing activity. C. To show evidence of incision healing. D. To take analgesics as prescribed.

Correct Answer is A

Explanation

Choice A Reason: This is correct because it reflects a measurable and realistic goal that addresses the client's problem of activity intolerance related to pain. Ambulation promotes circulation, prevents complications, and enhances recovery.

Choice B Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Avoiding pain-causing activity may lead to immobility and further complications.

Choice C Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Incision healing is an expected outcome of wound care, not activity.

Choice D Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Taking analgesics as prescribed may help relieve pain, but it does not promote activity.

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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

While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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