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 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.
Correct Answer is B,C,D,G,E,F,A
Explanation
Check the function of the suction catheter: Ensures the catheter is functioning properly before starting the procedure.
Don sterile gloves: Maintains asepsis during the suctioning procedure.
Adjust the suction to 120 to 150 mm Hg: Proper suction pressure prevents mucosal trauma.
Hyperoxygenate the client: Prevents hypoxia during the suctioning process.
Insert the catheter without suction: Prevents trauma to mucosa by reducing suction on insertion.
Apply intermittent suction while rotating the catheter: Effectively clears secretions while minimizing tissue damage.
Check for secretion clearance: Ensures the airway is clear and the procedure was effective.
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