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 D

Explanation

Choice A rationale
While antibiotics are used to treat bacterial infections, crackles in the lungs can be a sign of various conditions, not just bacterial infections. Therefore, administering antibiotics is not the appropriate action based solely on the finding of crackles.
Choice B rationale

Limiting fluid intake can be beneficial for clients with certain conditions such as heart failure, but it is not the appropriate action based solely on the finding of crackles.
Choice C rationale
Initiating bedrest in semi-Fowler’s position can help improve lung expansion and ease breathing in clients with certain respiratory conditions. However, it is not the appropriate action based solely on the finding of crackles.
Choice D rationale
Crackles can sometimes be cleared by deep breathing and coughing. Repeating the auscultation after asking the client to breathe deeply and cough can help the nurse determine if the crackles are transient (cleared by coughing) or persistent.

A. Call the family and ask them to make arrangements for someone to sit with the client. B. Obtain a prescription for medication to sedate the client. C. Check the client for injuries. D. Assist the client back into bed and apply restraints.

Correct Answer is C

Explanation

Choice A rationale

While involving the family in the care of an older adult client is important, calling the family to make arrangements for someone to sit with the client is not the immediate action the nurse should take. The nurse’s first responsibility is to ensure the client’s safety and well-being.
Choice B rationale
Obtaining a prescription for medication to sedate the client is not the immediate action the nurse should take. Sedating the client does not address the immediate concern of potential injury.
Choice C rationale
The nurse should first check the client for injuries. This is the immediate action because the client may have sustained injuries from the fall. The nurse should perform a thorough assessment to determine the extent of any injuries and provide appropriate care.
Choice D rationale
Assisting the client back into bed and applying restraints is not the immediate action the nurse should take. Restraints should be used as a last resort and only if less restrictive measures have been ineffective. Furthermore, restraints require a physician’s order.

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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

Upon auscultating a client’s lungs, the nurse identifies crackles in the left posterior base. What action should the nurse take?

Correct Answer is D

Explanation

A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. What action should the nurse take?

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?