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 B
Explanation
A. 25 and 50 mm Hg: This pressure is insufficient to effectively clear oral secretions.
B. 80 and 120 mm Hg: Recommended for safe and effective oral suctioning to prevent mucosal trauma while adequately clearing secretions.
C. 120 and 180 mm Hg: Excessive pressure can cause mucosal damage and trauma.
D. 50 and 75 mm Hg: This pressure is too low to be effective for adult oral suctioning.
Correct Answer is C
Explanation
A) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. Milking the chest tube is not recommended as it can create excessive negative pressure and damage lung tissue.
B) Notify the provider. This is not the first intervention. The nurse should assess the suction regulator and connections before notifying the provider.
C) Verify that the suction regulator is on. Lack of bubbling often indicates that the suction regulator is off or not functioning correctly. The nurse should first ensure that the regulator is turned on and properly connected.
D) Continue to monitor the client because this is an expected finding. Bubbling should be present in the suction control chamber if suction is applied; therefore, this finding requires immediate assessment.
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