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 C
Explanation
Choice A: Limitations to range of motion are not directly related to the application of a heating pad. A heating pad may help reduce pain and stiffness, but it does not affect the range of motion itself.
Choice B: Muscle strength and tone are also not directly related to the application of a heating pad. A heating pad may relax tense muscles, but it does not affect the strength or tone of the muscles.
Choice C: Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. A heating pad can cause burns or tissue damage if the patient has impaired sensation and cannot feel the heat or pain. The nurse should check the patient's ability to perceive temperature, pressure, and pain before applying a heating pad.
Choice D: Presence of rebound phenomenon is not relevant to the application of a heating pad. Rebound phenomenon refers to the worsening of symptoms after discontinuing a medication or treatment. A heating pad does not cause rebound phenomenon.
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