A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?
Perform a blind finger sweep.
Turn the client to the side.
Insert an oral airway.
Administer the abdominal thrust maneuver.
The Correct Answer is D
Choice A reason: Perform a Blind Finger Sweep
Performing a blind finger sweep is not recommended because it can push the foreign object further into the airway, making the obstruction worse. This method is only advised if the object is clearly visible and can be safely removed without causing further harm.
Choice B reason: Turn the Client to the Side
Turning the client to the side can be helpful in certain situations, such as when the client is unconscious or at risk of vomiting. However, in the case of a conscious client with a foreign body airway obstruction, this action does not directly address the obstruction and is not the first priority.
Choice C reason: Insert an Oral Airway
Inserting an oral airway is typically used to maintain an open airway in an unconscious patient who cannot maintain their own airway. For a conscious client with a foreign body obstruction, this action is not appropriate and could cause further complications.
Choice D reason: Administer the Abdominal Thrust Maneuver
Administering the abdominal thrust maneuver (also known as the Heimlich maneuver) is the recommended first action for a conscious client with a foreign body airway obstruction. This technique involves standing behind the client, placing a fist just above their navel, and delivering quick, upward thrusts to expel the foreign object. This method is effective in creating an artificial cough that can dislodge the obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
WBC count: An elevated white blood cell (WBC) count is a common indicator of infection. The body produces more white blood cells to fight off infections, making this a key marker for identifying infections in patients with pressure ulcers. Monitoring WBC count helps in assessing the presence and severity of an infection, guiding appropriate treatment.
Choice B reason:
BUN: Blood urea nitrogen (BUN) levels are used to assess kidney function and hydration status. Elevated BUN levels can indicate dehydration or kidney dysfunction but are not specific indicators of infection. While important for overall health assessment, BUN is not directly related to detecting infections in pressure ulcers.
Choice C reason:
Potassium: Potassium levels are crucial for maintaining normal cellular function, particularly in the heart and muscles. Abnormal potassium levels can indicate issues such as kidney dysfunction or electrolyte imbalances but do not specifically indicate infection. Monitoring potassium is important for overall health but not for diagnosing infections in pressure ulcers.
Correct Answer is B
Explanation
Choice A reason:
Saying “Maybe next time you can have a vaginal delivery” is not supportive and may minimize the client’s current feelings of disappointment. It is important to acknowledge and validate the client’s emotions rather than focusing on future possibilities.
Choice B reason:
This response, “It sounds like you are feeling sad that things didn’t go as planned,” is empathetic and validates the client’s feelings. It shows that the nurse is listening and understands the client’s disappointment, which is crucial for emotional support.
Choice C reason:
While it is true that having a healthy baby is important, saying “At least you know you have a healthy baby” can come across as dismissive of the client’s feelings. It is essential to address the client’s emotions directly rather than shifting the focus.
Choice D reason:
Telling the client “You can resume sensations sooner than if you had delivered vaginally” is not relevant to the client’s expressed feelings of disappointment about not having a natural childbirth. This response does not address the emotional aspect of the client’s experience.
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