The nurse approaches a panic-stricken man and suspects he is choking. Which clinical indicator cues the nurse to initiate nursing interventions immediately?
1. The client states he just ate a steak dinner.
2. The client coughs forcefully without results.
3. The nurse auscultates wheezing and rhonchi.
4. The client has a high-pitched inspiratory noise.
4
4. A high-pitched inspiratory noise is consistent with clinical indicators of an airway obstruction, especially with a client who is panic-stricken because the client is gasping for air. The nurse administers the Heimlich maneuver to the client who is standing or abdominal thrusts to a client who has collapsed to dislodge the obstruction and restore the client's airway. After successfully restoring the airway, the nurse sends the client to the emergency department because tracheal edema frequently follows an airway obstruction.
1, 2, and 3. If the client can talk, cough, or if the nurse auscultates air movement in the lungs, the client should be left alone but observed until the panic subsides.
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