A patient with a nasogastric tube to low intermittent suction after surgery begins to vomit bright red blood. Which action should the nurse take first?
a. Administer oxygen.
b. Irrigate the nasogastric tube.
c. Increase the intravenous rate.
d. Turn the patient onto his or her side.
ANS: D
Protection of the airway during vomiting is a priority to prevent aspiration. Those at risk of aspiration are persons who are unconscious, older, and experiencing gag reflex impairments. Place these types of persons on their side when they begin to vomit. This allows the gastric contents to be expelled from the mouth rather than pooling at the back of the throat and being aspirated. A. The patient does not necessarily need oxygen at this time. B. The patient could aspirate while the nurse is irrigating the nasogastric tube. C. There is no reason to increase the patient's intravenous infusion at this time.
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