The nurse observes a patient who is gagging and using this gesture (see illustration). What is the nurse's response?
1. Assume the patient is having throat pain and administer pain medication.
2. Prepare to perform the Heimlich maneuver.
3. Assess the patient for cyanosis, difficulty breathing, and stridor and wait until normal breathing resumes.
4. Sit with the patient until the laryngospasm passes and encourage deep breathing.
2
Rationale 1: Assuming the patient is having throat pain is an inappropriate response.
Rationale 2: The patient who is gagging and using the universal gesture for choking likely has an airway obstruction. The goal is to maintain an open airway and clear the obstruction. If the obstruction is complete, the Heimlich maneuver is performed.
Rationale 3: Assessing the patient is inappropriate; choking constitutes a life-threatening situation.
Rationale 4: Sitting with the patient is inappropriate; choking constitutes a life-threatening situation.
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