A client just experienced an episode of reflux with regurgitation. What assessment by the nurse is the priority?
a. Auscultate the lungs for crackles.
b. Inspect the oral cavity.
c. Check the oxygen saturation.
d. Teach the client to sleep sitting up.
A
The client with regurgitation is at risk for aspiration, pneumonia, and bronchitis. The nurse should auscultate the lungs for crackles—an indication of aspiration. If abnormalities are found, the nurse can then check the oxygen saturation. The nurse should teach the client to sleep with the head of the bed elevated, however; this is not a priority action. Inspecting the oral cavity probably is not needed.
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