A 70-year-old male presents to the emergency department with confusion and shortness of breath. Upon assessment, the nurse notes decreased breath sounds on auscultation. What is the most appropriate first action for the nurse to take?
Administer a bronchodilator to alleviate airflow obstruction.
Administer supplemental oxygen to the patient.
Order a chest X-ray to evaluate for pneumonia.
Reassess the patient’s respiratory status in one hour.
The Correct Answer is B
Choice A reason: While bronchodilators may be helpful if the underlying cause is bronchospasm (like asthma or COPD), they are not the immediate priority over addressing hypoxemia. The nurse must first stabilize the patient's oxygenation status before proceeding to targeted pharmacological interventions, which may require a provider order.
Choice B reason: Hypoxemia, as indicated by shortness of breath and clinical distress, is a medical priority. Administering oxygen is the most critical first action to stabilize the patient, improve tissue oxygenation, and prevent end-organ damage, particularly in a patient who is already showing signs of neurological change (confusion).
Choice C reason: A chest X-ray is a diagnostic tool, not an intervention. While it is necessary to determine the etiology of the respiratory distress, such as pneumonia or pleural effusion, it does not address the patient's acute need for oxygenation. The nurse must prioritize stabilization and oxygen therapy before diagnostic procedures.
Choice D reason: Reassessing in one hour is clinically dangerous for a patient presenting with both respiratory distress and neurological symptoms (confusion). These are signs of acute decompensation. The patient requires immediate intervention and continuous monitoring, not a delayed reassessment, as the condition could progress rapidly to respiratory failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Documenting patient complaints of chest pain is accurate, but the phrase "states it started an hour ago" is subjective. While necessary for the chart, objective documentation focuses on measurable data, whereas this entry is a mix of subjective reporting rather than a purely clinical physical assessment finding.
Choice B reason: Documentation of a plan is part of the nursing process, but it describes future intentions rather than a current objective assessment finding. Legal documentation requires a clear separation between what was physically observed during the assessment and the subsequent clinical orders or care planning steps taken.
Choice C reason: This entry is strictly objective, providing measurable hemodynamic data (blood pressure) and specific physical assessment findings (regular rhythm, bounding pulse). This level of detail is essential for legal and clinical accuracy, as it provides a verifiable record of the patient's physiological state during the examination.
Choice D reason: Describing a patient as appearing "anxious" or "seeming uncomfortable" relies on subjective interpretation of the patient's behavior. Objective documentation should describe the clinical observations that led to the conclusion, such as "patient pacing, respiratory rate 22/min, diaphoresis present," rather than using vague subjective labels.
Correct Answer is A
Explanation
Choice A reason: Deep breathing exercises help expand the alveoli and promote optimal gas exchange. An oxygen saturation of 88% is below the normal range, indicating potential hypoxemia. Encouraging deep breaths improves ventilation, prevents atelectasis, and can help raise oxygen saturation levels by increasing the surface area available for gas diffusion in the lungs.
Choice B reason: Opioid analgesics are central nervous system depressants that can significantly decrease the respiratory rate and depth. Administering an opioid to a client who is already hypoxemic could lead to further respiratory depression, worsen the hypoxemia, and potentially result in dangerous levels of hypercapnia and respiratory failure.
Choice C reason: While coughing helps clear secretions, relying on a schedule of every 4 hours is inadequate for a client experiencing active hypoxemia. Interventions for low oxygen saturation must be immediate and continuous to restore adequate tissue perfusion, rather than waiting for a delayed, infrequent nursing task.
Choice D reason: Decreasing the head of the bed (placing the client in a supine position) increases the pressure of the abdominal organs against the diaphragm, which limits lung expansion. To improve oxygenation, the nurse should elevate the head of the bed (Fowler's or semi-Fowler's position) to maximize thoracic excursion and ventilation.
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