Hesi RN Fundamentals of Nursing
Hesi RN Fundamentals of Nursing ( 44 Questions)
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 is not the correct action because it may worsen the choking and increase the risk of aspiration.
Review the advance directive document is not the correct action because it is not a priority in this situation. The nurse should act quickly to relieve the choking and prevent complications.
Elevate the head of bed 45 degrees is the correct action because it helps clear the airway and reduce vomiting.
Perform oropharyngeal suctioning is not the correct action because it may stimulate gagging and vomiting. The nurse should suction only if there is visible secretions or vomitus in the mouth.
Choice A: Irrigating the nasogastric tube with water is not the correct action because it may worsen the choking and increase the risk of aspiration.
Choice B: Reviewing the advance directive document is not the correct action because it is not a priority in this situation. The nurse should act quickly to relieve the choking and prevent complications.
Choice C: Elevating the head of the bed 45 degrees is the correct action because it helps clear the airway and reduce vomiting.
Choice D: Performing oropharyngeal suctioning is not the correct action because it may stimulate gagging and vomiting. The nurse should suction only if there are visible secretions or vomitus in the mouth.
