A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first?
a. Assess the client's endotracheal tube with 40% FiO2.
b. Insert an indwelling Foley catheter to gravity drainage.
c. Place the client's nasogastric tube to low intermittent suction.
d. Start lactated Ringer's solution through an intravenous catheter.
ANS: A
Using the ABCs, airway and oxygenation status should always be assessed first, so checking the endotracheal tube is the first action. Next, the nurse should start the IV line (circulation). After that, the Foley catheter can be inserted and the nasogastric tube can be set.
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