A nurse encounters an unresponsive client during a walk. The client's partner states, "He was pulling weed in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the client's airway?
Modified jaw thrust
Flexion of the head
Head-tilt, chin-lift maneuver
Hyperextension of the head
The Correct Answer is C
A. This technique is used to open the airway of a trauma client when a cervical spine injury is suspected, as it minimizes neck movement. Since there is no indication of trauma in this scenario, another method is preferred.
B. Flexing the head closes the airway by obstructing the trachea and should never be used to open the airway.
C. This is the correct technique to open the airway for an unresponsive, non-trauma client. The nurse tilts the head back and lifts the chin upward, which moves the tongue away from the posterior pharynx and opens the airway for ventilation.
D. Excessive hyperextension can injure the neck or narrow the airway. The correct technique involves a gentle tilt, not full hyperextension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This technique is used to open the airway of a trauma client when a cervical spine injury is suspected, as it minimizes neck movement. Since there is no indication of trauma in this scenario, another method is preferred.
B. Flexing the head closes the airway by obstructing the trachea and should never be used to open the airway.
C. This is the correct technique to open the airway for an unresponsive, non-trauma client. The nurse tilts the head back and lifts the chin upward, which moves the tongue away from the posterior pharynx and opens the airway for ventilation.
D. Excessive hyperextension can injure the neck or narrow the airway. The correct technique involves a gentle tilt, not full hyperextension.
Correct Answer is A
Explanation
A. Fidelity refers to keeping promises and being faithful to commitments made to clients. By returning at 1400 as the client requested and the nurse agreed, the nurse is demonstrating reliability, trustworthiness, and respect for the client’s expectations—key components of fidelity.
B. Autonomy involves respecting a client’s right to make independent decisions about their care. While honoring the client’s preference for wound care time supports autonomy, the nurse’s action specifically reflects keeping a promise, which defines fidelity.
C. Justice refers to fair and equal treatment of all clients, ensuring that resources, time, and care are distributed without bias. This scenario focuses on honoring a commitment, not on fairness or equality.
D. Veracity means telling the truth and being honest with clients. The scenario does not involve communication of truthfulness but rather following through on a promise, which aligns with fidelity.
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