A nurse in a long-term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver?
The client is coughing only.
The client is not making any sounds.
The client is able to whisper.
The client has a high-pitched inspiratory stridor.
The Correct Answer is B
A. A client who is coughing only is still able to clear the airway by themselves.
B. Inability to make any sounds indicates a complete airway obstruction, requiring the Heimlich maneuver.
C. A client who can whisper has a partial airway obstruction and should be encouraged to continue coughing.
D. A high-pitched inspiratory stridor indicates a partial obstruction, not requiring the Heimlich maneuver but close monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Emphasizing the significance of the information may not address the cultural behavior of avoiding direct eye contact.
B. Continuing with the discussion respects the client's cultural behavior, as some cultures view direct eye contact as disrespectful.
C. Stopping the instructions to see what is on the floor may misunderstand the client's cultural behavior.
D. Moving closer for eye contact may make the client uncomfortable if their culture views direct eye contact as inappropriate.
Correct Answer is D
Explanation
A. Administering lorazepam should not be the first action for managing agitation in a client with dementia as it can increase the risk of falls and other complications.
B. Using physical restraints such as raising side rails is not recommended as a first-line intervention and can increase agitation and risks.
C. Applying a vest restraint should be avoided as it restricts the client's movement and can increase agitation and risks.
D. Placing a seat alarm in the client's chair is an appropriate initial intervention to monitor the client's movements and ensure safety while allowing some freedom of movement.
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