A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify as requiring an abdominal thrust?
The client is grasping his abdomen.
The client is coughing.
The client cannot speak.
The client is hyperventilating.
The Correct Answer is C
A. The client is grasping his abdomen: Grasping the abdomen may indicate pain or cramping, not necessarily airway obstruction.
B. The client is coughing: Effective coughing suggests that the airway is partially open and the client is moving air, meaning abdominal thrusts are not required.
C. The client cannot speak: Inability to speak or cough is a sign of complete airway obstruction, indicating the need for abdominal thrusts.
D. The client is hyperventilating: Rapid breathing is not a typical sign of choking and does not warrant abdominal thrusts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "Repeat your breathing exercise every 2 hrs." Repeating breathing exercises should be done a couple of times every hour to help prevent postoperative complications such as atelectasis and pneumonia.
B) "Inhale through your mouth." Clients should inhale through their nose to filter, warm, and humidify the air.
C) "Hold your breath for 5 seconds." Holding the breath for 5 seconds allows for better lung expansion and optimal oxygen exchange.
D) "Exhale through your nose." Clients are generally advised to exhale through pursed lips to create positive airway pressure and prevent airway collapse.
Correct Answer is A
Explanation
A. Assist the client to Fowler's position: This position helps maximize lung expansion, making it easier for the client to breathe.
B. Promote removal of pulmonary secretions: Important but secondary to addressing immediate respiratory distress.
C. Increase the oxygen flow: This should only be done per provider order to avoid complications such as oxygen toxicity.
D. Obtain a specimen for arterial blood gases: This is a diagnostic step but not an immediate intervention for difficulty breathing.
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