The nurse assists the client who had a recent cerebral vascular accident (CVA or stroke) with feeding and the client begins to choke. Which intervention is the best choice to meet the client's priority need?
1. Provide oxygen.
2. Suction the client.
3. Call for assistance.
4. Recline the client.
2
2. The client's priority needs, in order, are airway, breathing, and circulation (A-B-Cs), so the nurse's priority action is to maintain the airway. To accomplish this, the nurse suctions the client to prevent an airway obstruction.
1. After the airway is clear, the nurse can provide supplemental oxygen as prescribed if the client continues to have difficulty or has oxygen desaturation from choking.
3. After suctioning the client, if the client continues to have difficulty, the nurse should call for help to obtain emergency equipment.
4. The nurse can place the client in the recovery position after choking if the client loses consciousness, continues to choke, or start to retch or vomit. Reclining the client is contraindicated because it increases the risk of aspiration.
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