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
Rationale: A. Ensure suction equipment is available: Having suction equipment readily accessible is an important safety measure for clients recovering from moderate sedation because protective airway reflexes may be diminished. However, simply ensuring availability does not immediately reduce the client’s risk of aspiration. Preparation alone does not address nausea. B. Auscultate bowel sounds: Assessing bowel sounds evaluates gastrointestinal motility but does not address the acute risk associated with nausea following sedation. Moderate sedation can impair gag and cough reflexes, increasing aspiration risk if vomiting occurs. Bowel assessment does not provide immediate protection against airway compromise. C. Administer ondansetron: Ondansetron is an antiemetic that blocks serotonin receptors in the chemoreceptor trigger zone and can reduce nausea and vomiting. Although appropriate, medication administration takes time to prepare and act, and it does not immediately protect the airway. In a sedated client, airway protection takes precedence over symptom treatment. D. Turn the client on their side: Positioning the client laterally helps prevent aspiration by allowing emesis to drain from the mouth rather than obstructing the airway. Clients recovering from moderate sedation may have decreased protective reflexes, increasing the risk of aspiration pneumonia. Immediate repositioning directly addresses airway safety.