The nurse is preparing to administer medication using a client’s nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply.

Choice A reason: The first priority in this situation is to ensure the client’s airway is secure. Difficulty breathing and stridor indicate a potential airway obstruction, which can be life-threatening. Activating the hospital’s emergency or rapid response system ensures that the client receives immediate medical attention from a team equipped to handle such emergencies. This step is crucial to prevent respiratory arrest and other complications.

Choice B reason: While placing a heart monitor on the client and observing for dysrhythmias is important, it is not the immediate priority in this scenario. The client’s airway and breathing take precedence over monitoring heart rhythms. Once the airway is secured and breathing is stabilized, then monitoring for dysrhythmias can be considered.

Choice C reason: Asking the charge nurse to come see the client immediately is a reasonable action, but it is not the most effective first step. The charge nurse may not have the necessary equipment or expertise to handle an acute airway obstruction. Activating the emergency or rapid response system ensures that a specialized team responds quickly.

Choice D reason: Checking the client’s blood pressure and heart rate is important for overall assessment, but it is not the immediate priority when there is a potential airway obstruction. Ensuring the client can breathe is the most critical action. Vital signs can be checked once the airway is secured.

Choice E reason: Providing a calm and assuring environment for the client is beneficial for reducing anxiety, but it does not address the immediate threat to the client’s airway. While maintaining a calm environment is important, the nurse must first ensure the client’s airway is open and breathing is adequate.

Choice F reason: Placing the emergency cart at the bedside is a preparatory step that can be useful, but it is not the first action to take. The nurse should first activate the emergency or rapid response system to get immediate help. The emergency cart can be brought to the bedside by the responding team.

Choice A Reason:

A 42-year-old man with gastroesophageal reflux disease (GERD) is not at the highest risk for obstructive sleep apnea (OSA). While GERD can be associated with OSA, it is not a primary risk factor. The main risk factors for OSA include obesity, age, and anatomical features that can obstruct the airway. Therefore, this individual is not at the greatest risk compared to others.

Choice B Reason:

A 55-year-old woman who is 50 lb (23 kg) overweight is at significant risk for developing OSA. Obesity is one of the most critical risk factors for OSA because excess weight can lead to fat deposits around the upper airway, which can obstruct breathing during sleep. Additionally, being overweight increases the likelihood of other conditions that can exacerbate OSA, such as hypertension and metabolic syndrome.

Choice C Reason:

A 20-year-old woman who is 8 months pregnant may experience temporary sleep disturbances, including snoring and mild sleep apnea, due to hormonal changes and increased abdominal pressure. However, pregnancy-related sleep apnea is usually transient and resolves after childbirth. Therefore, while she may have an increased risk during pregnancy, it is not as significant as the risk posed by obesity.

Choice D Reason:

A 73-year-old man with type 2 diabetes mellitus has an increased risk of OSA, as diabetes is associated with obesity and metabolic syndrome, which are risk factors for OSA. However, the presence of diabetes alone does not pose as high a risk as obesity. Therefore, while this individual is at risk, it is not as high as the risk associated with being significantly overweight.