A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next?
Prepare to initiate antibiotic therapy.
Obtain a prescription for a chest x-ray.
Position the client on their side.
Suction the client's orotracheal airway.
The Correct Answer is C
A. Prepare to initiate antibiotic therapy: Antibiotics may be necessary if aspiration pneumonia develops, but this is not an immediate nursing action. Medication initiation requires provider evaluation and a prescription, making this a delayed intervention.
B. Obtain a prescription for a chest x-ray: A chest x-ray may be ordered to confirm aspiration, but requesting this is not the nurse’s next priority. Immediate nursing interventions to protect the airway and prevent further complications must occur first.
C. Position the client on their side: Placing the client on their side helps prevent further aspiration and promotes drainage of secretions or feeding material from the airway. This is the safest immediate response after stopping the feeding.
D. Suction the client's orotracheal airway: Suctioning is appropriate if the client has visible secretions, is coughing ineffectively, or shows respiratory distress. However, the priority immediate action is to position the client to reduce aspiration risk before suctioning if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}
Explanation
Rationale for correct choices:
• Transfusion-associated circulatory overload: Characterized by dyspnea, cough, crackles in the lungs, jugular vein distention, and hypertension due to fluid overload during transfusion. The client’s findings of shortness of breath, cough, crackles, and distended neck veins directly align with this condition.
• Lung sounds: The presence of new crackles bilaterally along with dyspnea indicates fluid overload affecting pulmonary circulation, consistent with TACO.
Rationale for incorrect choices:
• Acute intravascular hemolytic reaction: This reaction presents with flank pain, fever, chills, and hemoglobinuria due to incompatible blood. The client shows no evidence of hematuria, fever spike, or severe back pain.
• Anaphylactic reaction: Anaphylaxis occurs rapidly, with symptoms such as bronchospasm, hypotension, urticaria, and possible shock. The client does not have a rash, hives, or hypotension, which rules this out.
• Febrile nonhemolytic reaction: Typically presents with fever, chills, and headache caused by donor WBCs. The client’s temperature is stable and no chills are reported, so this does not match.
• Sepsis transfusion reaction: This occurs when contaminated blood is transfused, leading to fever, hypotension, and rigors. The client is not hypotensive or febrile, making this less likely.
• Temperature: A temperature rise would point to a febrile or septic transfusion reaction, but the client’s temperature remained stable.
• Urticaria: Urticaria would suggest an allergic or anaphylactic reaction, which was not observed.
• Hypotension: Hypotension is seen with hemolytic or septic reactions, but this client’s blood pressure is elevated, not decreased.
• Chills: Chills are typical of febrile or hemolytic reactions, but the client did not report them.
Correct Answer is ["B","C","E"]
Explanation
A. Schedule the client as the last surgery of the day: Clients with latex allergy should ideally be scheduled as the first surgery of the day to minimize exposure to latex particles that may accumulate in the air and environment. Scheduling last increases exposure risk.
B. Notify ancillary departments of the client's allergy: Informing all relevant departments, such as pharmacy, radiology, and laboratory services, ensures that latex-free supplies are used consistently throughout the client’s care. This prevents accidental exposure to latex-containing products.
C. Label the surgical suite as latex-free: Clearly labeling the operating room reduces the risk of staff inadvertently bringing in latex products. It promotes team-wide awareness and helps maintain a safe surgical environment for the client.
D. Provide powdered gloves for the staff's use: Powdered latex gloves are contraindicated because they release latex proteins into the air, which increases the risk of allergic reactions. Only non-latex, powder-free gloves should be provided.
E. Ensure a latex allergy cart is available: Having a latex allergy cart stocked with latex-free supplies ensures that all necessary items are available during the procedure. This reduces delays and eliminates the need to search for suitable equipment during surgery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.