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    Ati Rn Adult Medical Surgical 2023 Proctored Exam

    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?

    Explanation & Rationale

    A. Assessing bowel sounds is not an immediate priority for a client experiencing nausea after sedation. While gastrointestinal assessment is important, the primary concern is airway protection. B. Nausea following sedation increases the risk of vomiting and aspiration. Turning the client on their side (recovery position) helps protect the airway by allowing vomitus to drain and reducing the risk of aspiration, which is a life-threatening complication. This is the priority intervention according to Maslow’s hierarchy and ABCs (Airway, Breathing, Circulation). C. While having suction available is important, it is preparatory. The immediate action is to position the client safely; suction is used if vomiting occurs. D. Administering an antiemetic may help relieve nausea, but it does not immediately protect the airway. Priority interventions always address airway, breathing, and circulation first.

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