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Difficulty: MediumBasic Care and Comfort

A client who recently returned to the clinical unit following an open appendectomy begins to actively vomit. The client is currently resting in bed in a semi-Fowler's position. Which immediate action should the practical nurse take to ensure the client's safety and comfort?

  1. A
    Lower the head of the bed to a flat, supine position to reduce abdominal tension.
  2. B
    Measure the client's vital signs to assess for early indicators of shock.
  3. Assist the client into a lateral side-lying position immediately.Answer
  4. D
    Instruct an unlicensed assistive personnel to perform deep oropharyngeal suctioning.

Answer

The most appropriate immediate action is to assist the client into a lateral side-lying position.
Assisting the client into a lateral side-lying position is the immediate priority. This position utilizes gravity to help clear the vomitus from the mouth and prevents aspiration into the lungs, thereby effectively securing the client's airway while promoting basic care and comfort.

Step-by-Step Solution

1
Identify the immediate threat to the client.
The client is actively vomiting while in a semi-Fowler's position, creating a high risk for aspiration of gastric contents.
Airway, Breathing, and Circulation (ABC) prioritization dictates that airway protection is the foremost concern in any clinical scenario.
2
Determine the most effective, scope-appropriate nursing intervention to protect the airway.
Turning the client to the side allows emesis to drain out of the mouth via gravity.
A lateral side-lying position prevents the aspiration of fluid into the lungs, effectively securing the airway while promoting basic comfort during recovery.

Key Concept

Prioritization of airway protection and safe positioning during active vomiting
Estimated Time:1m 0s
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Topics

Basic Care and Comfort

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