While in the dining room at the hospital, the nurse notes a visitor has forceful coughs. Which actions would the nurse take to assist this visitor?
Select all that apply:
Start cardiopulmonary resuscitation (CPR).
Assist the client to a sitting position on the floor.
Allow the visitor to cough.
Assess for a weak ineffective cough.
Perform the Heimlich maneuver.
Correct Answer : C,D
If a visitor in the dining room at the hospital has a forceful cough, the nurse should first allow the visitor to continue coughing. Coughing is a natural reflex that helps clear the airway of foreign objects or mucus. The nurse should also assess the effectiveness of the cough. If the cough is weak or ineffective, further intervention may be necessary.
Starting cardiopulmonary resuscitation (CPR) or performing the Heimlich maneuver would only be appropriate if the visitor is choking and unable to breathe. Assisting the client to a sitting position on the floor may not be necessary and could potentially cause harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement indicates a need for further teaching because it is not accurate. Positioning a client in good body alignment and changing the position regularly are essential aspects of nursing practice, but the position should be changed more frequently than every 3 hours. It is generally recommended to reposition clients at least every 2 hours to prevent pressure ulcers and other complications. The other options (Frequent change in position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures; Any position, correct or incorrect, can be detrimental if maintained for a prolonged period; and For all clients, it is important to assess the skin and provide skin care before and after a position change) are accurate statements and do not indicate a need for further teaching.
Correct Answer is D
Explanation
When collecting equipment to administer a unit of packed red blood cells, the nurse should use 250 mL of normal saline to initiate the IV for this transfusion ³. Normal saline is the only compatible solution to use with blood or blood components ³. The other options (100 mL of 5% dextrose and 1/2 normal saline, 1,000 mL of lactated Ringer's solution, and 500 mL of 5% dextrose and water) are not appropriate IV fluids to use when administering a unit of packed red blood cells.
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