A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence?

Correct Answer: A

Rationale: When a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.

Correct Answer: B

Rationale: In the context of oxygenation, understanding the process of digestion is crucial as it directly impacts the body's ability to absorb nutrients essential for oxygen transport and utilization within cells. The small intestine is indeed the site of the most important chemical digestion in the human body. This is because the small intestine is where the majority of nutrient breakdown and absorption occurs. Enzymes secreted by the pancreas and the small intestine itself play a critical role in breaking down carbohydrates, proteins, and fats into their basic building blocks for absorption. Additionally, the small intestine has a large surface area, thanks to its villi and microvilli, which increases the efficiency of nutrient absorption into the bloodstream. The other options can be ruled out based on their respective roles in the digestive process. The large intestine primarily absorbs water and electrolytes, rather than being a site for significant chemical digestion. The stomach plays a crucial role in the initial stages of digestion by secreting gastric juices and churning food, but the small intestine is where the bulk of chemical digestion occurs. The mouth initiates the mechanical breakdown of food through chewing and some enzymatic action from saliva, but the small intestine is where the majority of nutrient breakdown and absorption takes place. Educationally, understanding the specific functions of each part of the digestive system not only aids in answering questions like this on exams but also provides a foundational knowledge for healthcare professionals to understand how nutrients, including oxygen, are processed and utilized by the body. This knowledge is essential for providing holistic patient care and addressing any issues related to oxygenation that may stem from nutritional deficiencies.

Correct Answer: D

Rationale: Educational Rationale: The correct answer is option D: Chicken, Peanuts, Bananas, Wheat germs, and yeasts. Alcoholics often suffer from thiamine (B1) deficiency due to poor dietary habits and impaired absorption, leading to conditions like Wernicke's encephalopathy. Thiamine-rich foods like peanuts, wheat germ, and yeast are essential for these individuals to prevent such neurological complications. Option A includes pork liver and organ meats, which are high in iron but do not specifically address thiamine deficiency common in alcoholics. Option B lists red meat, eggs, and dairy products, which are good protein sources but do not provide the necessary thiamine. Option C suggests green leafy vegetables, yellow vegetables, cantaloupe, and dairy products, which are nutritious but not rich sources of thiamine needed to counter alcohol-induced deficiency. In an educational context, it is crucial for healthcare providers to understand the specific nutritional needs of alcoholics to address potential deficiencies and prevent associated health complications. Teaching the importance of thiamine-rich foods like those in option D can help caregivers support the recovery and overall well-being of alcoholic clients. This knowledge is pertinent for nursing practice, especially in caring for individuals with substance use disorders, ensuring a holistic approach to their health needs.

Correct Answer: A

Rationale: In the context of oxygenation and NGT feeding, positioning a terminally ill cancer patient in a semi-Fowler's position (30-45°) is crucial for several reasons. Firstly, this position helps reduce the risk of aspiration during feeding by preventing regurgitation of food and fluids into the lungs. By keeping the patient's head elevated, gravity assists in keeping the contents of the stomach down and decreasing the likelihood of reflux. Conversely, positioning the patient in a supine position (option D) increases the risk of aspiration as the patient's head is flat, allowing for easier reflux into the airway. Placing the patient in a chair (option B) may also increase the risk of aspiration as the patient may not be adequately supported or positioned for safe feeding. The slightly elevated right side lying position (option C) is used for patients at risk for aspiration related to decreased gastric emptying, typically for patients with a nasogastric tube for decompression, not for feeding purposes. Educationally, understanding the rationale behind proper positioning for NGT feeding is essential for nursing practice. It ensures patient safety, prevents complications such as aspiration pneumonia, and promotes optimal delivery of nutrition and medications. Nurses need to be knowledgeable about correct positioning techniques to provide quality care and prevent adverse events in patients with compromised health statuses, such as terminally ill cancer patients.

Correct Answer: D

Rationale: The correct answer, D) To promote CO2 elimination, is the primary reason to teach pursed lip breathing to clients with emphysema. Pursed lip breathing involves breathing in through the nose and breathing out slowly through pursed lips, which creates back pressure in the airways. This back pressure helps keep the airways open longer during exhalation, preventing them from collapsing and trapping air in the lungs. By prolonging exhalation, pursed lip breathing facilitates the removal of excess carbon dioxide (CO2) from the lungs, which is particularly beneficial for individuals with emphysema who struggle with impaired gas exchange. Option A, promoting oxygen uptake, is incorrect because pursed lip breathing primarily focuses on improving CO2 elimination rather than oxygen uptake. While improved oxygenation can be a secondary benefit of pursed lip breathing through its effects on gas exchange, it is not the primary goal for clients with emphysema. Option B, strengthening the diaphragm, is incorrect because pursed lip breathing is more about controlling exhalation and reducing air trapping rather than specifically targeting diaphragm strengthening. While pursed lip breathing can indirectly involve the diaphragm, its main purpose lies in improving ventilation and gas exchange in individuals with lung conditions like emphysema. Option C, strengthening the intercostal muscles, is also incorrect as the primary goal of pursed lip breathing is not to strengthen the intercostal muscles. While these muscles are involved in the breathing process, the main focus of pursed lip breathing in emphysema is to assist in CO2 elimination and alleviate symptoms related to air trapping and reduced lung function. Educationally, it is crucial for healthcare providers to understand the rationale behind using pursed lip breathing in clients with emphysema to optimize respiratory care interventions. By teaching and reinforcing this technique, healthcare professionals can empower clients to better manage their condition and improve their quality of life through enhanced respiratory function.