A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?

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

Slap the guest on the back several times.

Perform the Heimlich maneuver on the guest.

Observe the guest before taking further action.

Answer and Explanation

The Correct Answer is C

A. Assist the guest to the floor and begin mouth-to-mouth resuscitation: The airway is still obstructed, and rescue breathing is not effective until the obstruction is cleared.
B. Slap the guest on the back several times: Back slaps are not recommended for adults with complete airway obstruction as they may worsen the blockage.
C. Perform the Heimlich maneuver on the guest: Grasping the throat and inability to talk indicate a complete airway obstruction, requiring immediate abdominal thrusts (Heimlich maneuver) to clear the airway.
D. Observe the guest before taking further action: Delaying intervention in the presence of complete obstruction can lead to respiratory arrest. Immediate action is required.

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Correct Answer is D

Explanation

A. Loop the client's tubes carefully to prevent kinking: Tubes should not be unnecessarily looped, as this may cause obstruction or tension.
B. Clamp the tube when the client is ambulating: Clamping increases the risk of tension pneumothorax and should be avoided unless prescribed for specific procedures.
C. Place the client flat to avoid leaks in the tubing: This position may compromise lung expansion; semi-Fowler’s or Fowler’s position is preferred.
D. Keep the collection device below the client’s chest level: This position uses gravity to prevent backflow of fluid or air into the pleural space.

A. sitting upright and forward with arms supported on an over the bed table B. semi-Fowler's position with a single pillow behind the head C. high Fowler's position without a pillow behind the head D. right lateral with the head of the bed elevated 45 degrees.

Correct Answer is A

Explanation

A. Sitting upright and forward with arms supported on an over-the-bed table: This tripod position allows for maximum lung expansion by reducing pressure on the diaphragm and improving airflow, especially for patients with chronic obstructive pulmonary disease (COPD).
B. Semi-Fowler's position with a single pillow behind the head: This position does not optimize lung expansion as well as the tripod position.
C. High Fowler's position without a pillow behind the head: Although better than lying flat, this position lacks arm support, which helps in leveraging accessory muscles for breathing.
D. Right lateral with the head of the bed elevated 45 degrees: This position is not beneficial for promoting effective lung expansion in patients with emphysema.

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A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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