A nurse is caring for a client who reports feeling nauseous immediately following a procedure using moderate (conscious) sedation. Which of the following should be the nurse's priority action?
Auscultate bowel sounds.
Turn the client on their side.
Administer ondansetron.
Ensure suction equipment is available.
The Correct Answer is B
Rationale:
A. Auscultate bowel sounds: While assessing bowel sounds can be important, it is not the priority action in this situation. The client is experiencing nausea, and the priority is to ensure their airway and safety, not just bowel function.
B. Turn the client on their side: Turning the client on their side is the priority action. This position helps prevent aspiration in case the client vomits, ensuring the airway remains clear and reducing the risk of aspiration pneumonia, especially after sedation.
C. Administer ondansetron: While ondansetron is effective for treating nausea, it is not the priority action in this case. The nurse should first ensure the client's safety by positioning them appropriately to prevent aspiration before administering medication.
D. Ensure suction equipment is available: Having suction equipment available is important for safety, but the immediate priority is positioning the client to prevent aspiration. Once the client is positioned safely, suction can be used if necessary, or be obtained if unavailable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Vasovagal bradycardia without syncope: Vasovagal bradycardia, which is often caused by a reflex response to certain triggers, typically does not require a pacemaker. If the client is not experiencing syncope, a pacemaker is generally not indicated.
B. Sinus tachycardia with rates faster than 80/min: Sinus tachycardia is generally not an indication for a pacemaker. A heart rate faster than 80/min is often a physiological response to various conditions, such as exercise or stress, and usually does not require pacing unless.
C. Asymptomatic second-degree AV block: Asymptomatic second-degree AV block does not always require a pacemaker. Many individuals with this type of block do not experience significant symptoms, and treatment may not be necessary unless the block progresses.
D. Complete AV block with rates slower than 40/min: A complete AV block with a heart rate slower than 40/min is a serious condition that often requires the placement of a permanent pacemaker. This type of block disrupts the normal conduction between the atria and ventricles, leading to slow heart rates and inadequate cardiac output.
Correct Answer is B
Explanation
Rationale:
A. Weak peripheral pulses on palpation: Weak peripheral pulses can indicate poor circulation or low cardiac output, which is not a therapeutic response to synchronized cardioversion. The goal is to restore a normal rhythm and improve perfusion.
B. Cardiac monitor indicates sinus rhythm: Sinus rhythm on the cardiac monitor indicates that the cardioversion was successful in restoring a normal heart rhythm, making this the therapeutic response. This is the desired outcome after synchronized cardioversion.
C. Diminished breath sounds on auscultation: Diminished breath sounds are more indicative of respiratory issues, such as fluid in the lungs or atelectasis, and are not related to the effectiveness of synchronized cardioversion.
D. Pacer spikes precede the QRS complex on the ECG tracing: Pacer spikes are seen in patients with a pacemaker, not typically following synchronized cardioversion. If pacer spikes are seen, it indicates that pacing is occurring, which may be necessary in some situations, but it is not a sign of the success of cardioversion.
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