A client is in a left side lying position while the practical nurse (PN) is making the occupied bed. The PN observes that the client is experiencing orthopnea. Which action should the PN implement?
Turn the client to a supine position and elevate the head of the bed.
Obtain a pulse oximeter to measure the client's oxygen saturation.
Advise the client to rest while remaining in a side lying position.
Tuck the sheets under the client and roll the client to the right side.
The Correct Answer is A
Rationale:
A. Turn the client to a supine position and elevate the head of the bed is correct because orthopnea—difficulty breathing when lying flat—is often relieved by sitting upright or semi-Fowler’s position. Elevating the head of the bed reduces venous return to the heart and decreases pulmonary congestion, improving respiratory comfort.
B. Obtain a pulse oximeter to measure the client's oxygen saturation is incorrect as the first action. While monitoring oxygen saturation is important, the priority is to relieve respiratory distress.
C. Advise the client to rest while remaining in a side lying position is incorrect because side lying may not adequately relieve orthopnea, especially if pulmonary congestion is present. Upright positioning is more effective.
D. Tuck the sheets under the client and roll the client to the right side is incorrect because repositioning laterally does not address orthopnea and may worsen respiratory discomfort if the client prefers an upright posture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. This option is correct because when blood pressure is measured in the thigh, the cuff bladder should be positioned over the popliteal artery, which is located on the posterior aspect of the thigh. Proper artery alignment is essential for obtaining an accurate blood pressure reading.
B. This option is incorrect because while cuff placement must be appropriate, specifying a distance of six inches above the knee is inaccurate. Proper placement focuses on correct artery alignment rather than an arbitrary measurement.
C. This option is incorrect because blood pressure should not be taken in an arm with an arteriovenous fistula due to the risk of damaging the fistula and compromising circulation. The cast on the opposite arm also prevents its use.
D. This option is incorrect because systolic blood pressure values should not be adjusted or altered when documenting results. Using the correct cuff size improves accuracy; values are recorded as measured without subtraction.
Correct Answer is C
Explanation
Rationale:
A. Healthcare provider (HCP) notified, client refuses to have blood glucose taken is partially correct but does not include the client’s statement, which is important for accurate and objective documentation.
B. Blood glucose not obtained because client no longer wants to have finger stick is incorrect because it is subjective and does not include notification of the HCP or the client’s exact words.
C. Refused finger stick and states, "My finger is sore and test useless." Healthcare provider (HCP) notified is correct because it objectively documents the client’s refusal, includes the exact words in quotation marks for accuracy, and notes that the HCP was notified, which is required for continuity of care and legal purposes.
D. Healthcare provider (HCP) notified that client is uncooperative and irritable, glucose level not assessed is incorrect because it uses judgmental and subjective language (“uncooperative and irritable”), which is inappropriate for professional documentation.
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