A nurse is at a social event when another guest suddenly coughs weakly once, grasps her throat with her hands, and is unable to speak.
What action should the nurse take?

Assist the guest to the floor and begin mouth-to-mouth resuscitation.

Perform the Heimlich maneuver on the guest.

Observe the guest before taking further action.

Slap the guest on the back several times.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Assisting the guest to the floor and beginning mouth-to-mouth resuscitation is not the appropriate initial response. The guest’s symptoms indicate choking, and the Heimlich maneuver is the recommended first aid response.
Choice B rationale

The Heimlich maneuver is the correct response when someone is choking. The guest’s symptoms of a weak cough, inability to speak, and grasping the throat are classic signs of choking.
Choice C rationale
Observing the guest before taking further action is not appropriate in this situation. Immediate action is required to clear the guest’s airway.
Choice D rationale
Slapping the guest on the back is not the recommended response for choking in adults. It can potentially cause the object to become more deeply lodged in the throat.

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Correct Answer is A

Explanation

The correct answer is Choice A. The client is receiving an oxygen concentration of 28%. Nasal cannulas can deliver oxygen at a flow rate ranging from 1 to 6 liters per minute (L/min), with

each additional liter increasing the fraction of inspired oxygen (FiO2) by 4%. Therefore, at 2 L/min, the client is receiving an oxygen concentration of 28%78.

A. There is slough on part of the wound area. B. There appears to be persistent reddening of the skin. C. There is full-thickness skin loss with a crater. D. There is a fluid-filled area under the skin.

Correct Answer is C

Explanation

Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying

muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.

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A nurse is at a social event when another guest suddenly coughs weakly once, grasps her throat with her hands, and is unable to speak. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration is the client receiving?

Correct Answer is A

Explanation

Upon inspecting a client’s skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which statement best describes a stage 3 pressure ulcer?

Correct Answer is C

Explanation

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A nurse is at a social event when another guest suddenly coughs weakly once, grasps her throat with her hands, and is unable to speak.
What action should the nurse take?