A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?
Perform the Heimlich maneuver.
Slap the client on the back several times.
Assist the client to the floor and begin mouth-to-mouth resuscitation.
Observe the client before taking further action.
The Correct Answer is A
Choice A reason:
The Heimlich maneuver, also known as abdominal thrusts, is the recommended first aid technique for a conscious person who is choking. This maneuver helps to expel the object blocking the airway by using the air remaining in the lungs to force it out. The nurse should stand behind the person, place their arms around the person’s waist, make a fist with one hand, and place it just above the navel. The other hand should grasp the fist, and quick, upward thrusts should be performed until the object is expelled.
Choice B reason:
Slapping the client on the back several times is not the recommended first action for a conscious adult who is choking. While back blows can be effective, they are typically used in combination with abdominal thrusts and are more commonly recommended for infants. For adults, the Heimlich maneuver is preferred as the initial response.
Choice C reason:
Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate for a conscious person who is choking. Mouth-to-mouth resuscitation, or rescue breathing, is used when a person is not breathing and is unresponsive. In this scenario, the client is conscious but unable to speak, indicating a blocked airway that requires the Heimlich maneuver.
Choice D reason:
Observing the client before taking further action is not advisable in a choking emergency. Immediate intervention is crucial to prevent the situation from worsening. If the person is unable to speak, cough, or breathe, the Heimlich maneuver should be performed without delay.
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Correct Answer is B
Explanation
Choice A reason: While some women may start producing milk as early as 24 to 48 hours after delivery, this is not the typical timeframe for most women. The initial milk produced is colostrum, which is different from the mature milk that comes in later.
Choice B reason: For most women, breast milk “comes in” around 3 to 5 days postpartum. This period marks the transition from colostrum to mature milk, which is more abundant and nutritionally rich. During this time, mothers may experience breast engorgement and increased milk production.
Choice C reason: Breast milk typically does not take about 10 days to come in. By this time, most women will have already transitioned to mature milk. If milk production has not started by this time, it may indicate a problem that requires medical attention.
Choice D reason: The timeframe of 6 to 8 days is also not typical for the initial onset of mature milk production. Most women will have their milk come in within the first week postpartum.
Correct Answer is B
Explanation
Choice A reason:
Inserting a nasogastric tube is not the first-line intervention for postoperative nausea and vomiting (PONV). This invasive procedure is typically reserved for severe cases where other interventions have failed.
Choice B reason:
Administering an antiemetic is the appropriate action. Antiemetics help control nausea and vomiting, which are common side effects of opioids like morphine. This intervention can provide immediate relief and improve the client’s comfort.
Choice C reason:
Auscultating bowel sounds is important for assessing gastrointestinal function, but it does not directly address the immediate symptom of nausea and vomiting. This assessment can be part of the overall evaluation but is not the primary intervention.
Choice D reason:
Encouraging the client to ambulate is beneficial for overall recovery and can help reduce the risk of complications such as deep vein thrombosis. However, it does not directly address the immediate issue of nausea and vomiting.