A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?

Document the presence of orthopnea.

Elevate the head of the bed.

Obtain a pulse oximeter.

Assess the client's vital signs.

Answer and Explanation

The Correct Answer is B

A.   Orthopnea is a condition where a person has difficulty breathing when lying flat and may require sitting or standing to breathe more easily. While documenting orthopnea is important for the medical record and understanding the client’s condition, it is not the immediate priority in addressing acute breathing difficulty.
B.   Elevating the head of the bed is an immediate and effective action to help alleviate breathing difficulty. This position helps improve respiratory mechanics by allowing the diaphragm to move more freely and reducing pressure on the lungs.
C.   Using a pulse oximeter to measure oxygen saturation is important for assessing the client’s oxygen levels and determining the need for supplemental oxygen. However, this action is secondary to immediately addressing the position that is causing difficulty.
D.   Assessing vital signs is important for a comprehensive evaluation of the client’s overall condition and to identify any critical changes in health status. However, in the case of immediate breathing difficulty, it is more urgent to take actions that directly address the breathing issue before performing a thorough assessment.

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Correct Answer is C

Explanation

A. While practicing strength-building exercises for the arms, such as isometric exercises for the biceps and triceps, is beneficial for overall crutch use, it does not directly indicate proper crutch walking technique.
B. This choice is not correct for a three-point gait, especially in the case of a broken foot. In a three-point gait, the client should avoid bearing weight on the affected leg, as this gait is used to promote healing of a non-weight-bearing limb.
C. This behavior indicates a correct understanding of crutch walking. In the three-point gait, the client should bear weight on the crutches' handles and not on the armpits, which helps prevent nerve damage and provides better stability.
D. While it is important for safety to ensure that the rubber tips of the crutches are intact and not worn out, this behavior does not directly demonstrate the client’s understanding of the three-point gait technique.

A. Measure blood pressure in both arms. B. Assess skin turgor for elasticity. C. Observe the skin for signs of bruising. D. Note the rhythm of the pulse.

Correct Answer is D

Explanation

A. While it is generally good practice to measure blood pressure in both arms for a comprehensive assessment, this is not the primary concern with hypocalcemia. Hypocalcemia primarily affects neuromuscular and cardiovascular systems, so while blood pressure monitoring is important, it does not directly address the critical symptoms associated with low calcium levels.
B. Assessing skin turgor is a useful practice for evaluating hydration status and skin elasticity but is not specifically related to the management or symptoms of hypocalcemia. In hypocalcemia, skin changes are not the most relevant concern compared to neuromuscular symptoms.
C. Hypocalcemia can increase the risk of bleeding and bruising due to impaired blood clotting mechanisms. Monitoring for bruising can be an important aspect of assessing the effects of low calcium levels on the client’s hemostatic function. Bruising can be a direct indicator of the impact of hypocalcemia on blood coagulation and is relevant to the clinical management of the condition.
D. Hypocalcemia can affect cardiac function, potentially leading to changes in heart rhythm and rate. Monitoring the rhythm of the pulse is crucial, as it can help identify arrhythmias or other cardiac disturbances associated with low calcium levels.

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A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer is C

Explanation

A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs? Reference Range: Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]

Correct Answer is D

Explanation

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