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Rationale:
Answer: 4 Airway patency is the priority for this patient and the first thing the nurse should do is take measures to ensure the airway will be patent by making sure suction is readily available. Intractable nausea and vomiting pose a safety risk for aspiration. The other choices are all acceptable actions, but ensuring there is a patent airway is the first thing the nurse should do.
Additional Info:
Focus
Prioritization
QSEN
Patient-Centered Care
Concept
Gas Exchange
Practice Question Sourced From: Resources for Prioritization, Delegation, and Assignment, 5th Edition