A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Administer oxygen to the client.
Notify the charge nurse.
Document client findings and interventions taken.
Place the client in high Fowler's position.
The Correct Answer is D,A,B,C
D. Place the client in high Fowler’s position. Positioning the client upright maximizes lung expansion and improves oxygenation. This is the first step to alleviate respiratory distress before additional interventions.
A. Administer oxygen to the client. Once the client is positioned appropriately, providing supplemental oxygen helps increase oxygen saturation and relieve hypoxia. The nurse should titrate oxygen as needed according to facility protocols or provider orders.
B. Notify the charge nurse. After immediate interventions are in place, the nurse should inform the charge nurse to ensure further assessment and necessary medical interventions. The charge nurse may escalate care or contact the provider for additional management.
C. Document client findings and interventions taken. Once the client’s condition has been addressed and reported, documentation is necessary to record assessment findings, interventions provided, and the client's response. Accurate documentation ensures continuity of care and legal protection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will stop what I am doing and lie down." Stopping activity and resting helps reduce myocardial oxygen demand, which can relieve stable angina. Lying down also minimizes strain on the heart and decreases the risk of injury if the client becomes lightheaded.
B. "I will call the provider after taking one dose of nitroglycerin." Clients with stable angina should take one dose of sublingual nitroglycerin and wait five minutes. If pain persists after three doses taken five minutes apart, emergency medical services should be contacted instead of waiting to call the provider.
C. "I will hold my breath and bear down." The Valsalva maneuver can increase vagal tone, leading to bradycardia and decreased cardiac output, which may worsen angina rather than relieve it. This is not an appropriate response to chest pain.
D. "I will take two 325 milligram aspirin tablets at the same time." While aspirin is beneficial for preventing platelet aggregation, the usual recommended dose for acute chest pain is a single 160–325 mg tablet chewed immediately. Taking two full-dose aspirin tablets is unnecessary and may increase the risk of bleeding.
Correct Answer is D
Explanation
A. Apply intermittent suction for 30 seconds. Suctioning should not exceed 10-15 seconds to minimize hypoxia and irritation to the airway. Continuous suctioning for 30 seconds can lead to discomfort and inadequate oxygenation.
B. Apply suction while inserting the catheter. Suction should not be applied while inserting the catheter. This technique can cause trauma to the mucosa and prevent effective suctioning. Suction should only be applied once the catheter is in the desired position.
C. Insert the catheter 10 cm (4 in). The appropriate insertion depth for nasopharyngeal suctioning is typically 12-15 cm (5-6 in) for adults. Inserting the catheter to the proper depth ensures effective suctioning of secretions while minimizing the risk of injury.
D. Wait 1 min between suctioning attempts. Waiting 1 minute between suctioning attempts is essential to allow for adequate oxygenation and to prevent trauma to the airway. This interval allows the client to recover and ensures the airway is not overly irritated or compromised.
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