A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?

Assist the guest to the floor and begin mouth-to-mouth resuscitation.

Slap the guest on the back several times.

Perform the Heimlich maneuver on the guest.

Observe the guest before taking further action.

Answer and Explanation

The Correct Answer is C

A. Assist the guest to the floor and begin mouth-to-mouth resuscitation: The airway is still obstructed, and rescue breathing is not effective until the obstruction is cleared.
B. Slap the guest on the back several times: Back slaps are not recommended for adults with complete airway obstruction as they may worsen the blockage.
C. Perform the Heimlich maneuver on the guest: Grasping the throat and inability to talk indicate a complete airway obstruction, requiring immediate abdominal thrusts (Heimlich maneuver) to clear the airway.
D. Observe the guest before taking further action: Delaying intervention in the presence of complete obstruction can lead to respiratory arrest. Immediate action is required.

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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.

A. Pleural friction rub B. Rhonchi C. Stridor D. Vesicular

Correct Answer is D

Explanation

A. Pleural friction rub: An adventitious sound that occurs due to inflamed pleural surfaces rubbing against each other during respiration.
B. Rhonchi: A low-pitched, continuous adventitious lung sound typically caused by airway obstruction or secretions.
C. Stridor: A high-pitched adventitious sound caused by upper airway obstruction.
D. Vesicular: A normal breath sound heard over most of the lung fields, characterized by a soft, low-pitched rustling sound.

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A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is B,C,D,G,E,F,A

Explanation

Which of the following is not considered an adventitious lung sound upon auscultation:

Correct Answer is D

Explanation

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