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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View Related questions
Correct Answer is D
Explanation
Choice A reason:
A client with a tracheostomy tube attached to humidified oxygen is not typically at risk for hypokalemia. The primary concerns for these clients are maintaining a patent airway, preventing infection, and ensuring adequate humidification to prevent mucus plugging.
Choice B reason:
A client with an indwelling urinary catheter to gravity drainage is not specifically at risk for hypokalemia. The main risks for these clients include urinary tract infections and ensuring proper catheter care to prevent blockages.
Choice C reason:
A client with a chest tube to water seal is primarily at risk for complications related to the chest tube itself, such as infection, pneumothorax, or improper drainage. Hypokalemia is not a common risk associated with chest tubes.
Choice D reason:
A client with a nasogastric tube to suction is at risk for hypokalemia. Continuous suctioning can lead to the loss of gastric contents, which contain potassium, leading to a decrease in potassium levels in the body. This can result in hypokalemia, which needs to be monitored and managed appropriately.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A: Evaluate for the presence of a Babinski reflex
The Babinski reflex, also known as the plantar reflex, is a normal reflex in infants up to 2 years old. When the sole of the foot is stroked, the big toe moves upward, and the other toes fan out. This reflex helps assess the neurological function and integrity of the corticospinal tract. In the context of a subdural hematoma, evaluating the Babinski reflex can help determine if there is any neurological impairment or increased intracranial pressure, which could indicate worsening of the condition.
Choice B: Measure the head circumference
Measuring the head circumference is crucial in infants, especially those with head injuries, as it helps monitor brain growth and detect any abnormal swelling or increased intracranial pressure. An increase in head circumference can indicate the presence of intracranial bleeding or edema, which requires immediate medical attention. Regular monitoring of head circumference allows healthcare providers to track the infant’s neurological development and identify any deviations from the normal growth curve.
Choice C: Assess the pupillary reaction to light
Assessing the pupillary reaction to light is an essential neurological assessment in infants with head injuries. The pupils’ response to light provides information about the function of the optic nerve and the brainstem. A normal pupillary reaction indicates that the brainstem is functioning correctly, while an abnormal reaction can suggest increased intracranial pressure or brain injury. In this case, the nurse should assess the pupillary reaction to ensure there are no signs of neurological deterioration.
Choice D: Encourage parents to feed the infant
Encouraging parents to feed the infant is not recommended in this scenario. The infant’s inability to awaken for feeding and sleeping through the vital sign assessment could indicate a decreased level of consciousness or neurological impairment. Feeding an infant in such a state could increase the risk of aspiration and further complications. Instead, the nurse should focus on monitoring the infant’s neurological status and ensuring their safety.
Choice E: Palpate fontanel level
Palpating the fontanel level is an important assessment in infants with head injuries. The fontanels, or soft spots on the infant’s skull, provide valuable information about intracranial pressure. A bulging fontanel can indicate increased intracranial pressure, while a sunken fontanel may suggest dehydration. In this case, the nurse should palpate the fontanel to assess for any abnormalities that could indicate changes in the infant’s condition.
