The nurse is in the room of a client who is sleeping in bed. The client experiences an episode of reflux with regurgitation. Which action does the nurse take first?
a. Have the client roll to the side.
b. Raise the head of the client's bed.
c. Auscultate the client's lung sounds.
d. Call the Rapid Response Team.
B
The immediate danger for this client is aspiration. The nurse first should raise the head of the bed to reduce this risk. Asking the client to roll to the side will take too much time. The nurse can auscultate the client's lungs after raising the head of the bed. Calling the Rapid Response Team may or may not be necessary but would be done after the client is in a safer position.
You might also like to view...
A high school class is still mourning the death of a popular classmate who was killed in an automobile accident
The opportunity to conduct a class on safe driving would be based upon which facilitator of learning? 1. Repetition 2. Motivation 3. Simple to complex 4. Physical readiness
When caring for a geriatric client diagnosed with bipolar disorder, which manifestation of the disease is anticipated?
A) The disease remits as the client ages. B) The disease increases as the client ages. C) The depression increases as the client ages. D) The manic phase increases as the client ages.
A concept which can be measured using a hypotheses and may be tested is considered which of the following?
A) Theoretical B) Operational C) Abstract D) Nonvariable
Which of the following does not predispose to kidney stone formation?
A. Increased concentration of salts in the urine B. Infection of the urinary tract C. Increased concentration of protein in the urine D. Urinary tract obstruction