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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Turn on fans in the facility to circulate air." Fans should not be turned on during a chemical disaster because they can spread contaminants throughout the facility, increasing exposure to toxic substances.
B. "Open the fireplace dampers in the day room." Opening fireplace dampers can allow contaminated air to enter the facility, increasing the risk of exposure. Sealing off potential entry points for hazardous chemicals is a priority in these situations.
C. "Cover the electrical outlets with wet towels." While sealing gaps and vents can help reduce chemical exposure, using wet towels over electrical outlets is not an effective protective measure. Instead, doors, windows, and ventilation systems should be sealed as much as possible to prevent outside air from entering.
D. "Move clients to a room above ground with few windows." In an external chemical disaster, sheltering in place is essential. A room above ground is preferable because many chemicals are heavier than air and can accumulate in lower levels. Selecting a space with few windows helps minimize exposure by reducing potential entry points for contaminants.
Correct Answer is ["A","B"]
Explanation
A. Encourage oral fluid intake. The client has pink urine, which may indicate mild hematuria. While the urine output is adequate, increasing fluid intake can help dilute the urine, reduce irritation, and promote overall hydration. Additionally, increased fluid intake can aid in softening stool and preventing further constipation.
B. Administer an enema. The client reports abdominal cramping and a small, hard, painful bowel movement, indicating constipation. Postoperative clients are at risk for constipation due to decreased mobility, opioid pain medications, and anesthesia effects. Administering an enema can help relieve discomfort and promote bowel movements.
C. Irrigate indwelling catheter with 500 mL of fluid. The client's urinary catheter is intact, and there is a consistent urine output of 100 mL/hr. The presence of pink urine does not indicate obstruction requiring catheter irrigation. Irrigation with such a large volume could introduce unnecessary risk and is not warranted at this time.
D. Assist the client with a sitz bath. Sitz baths are typically used for perineal discomfort, such as after perineal surgery, hemorrhoids, or childbirth. There is no indication in the nurse’s notes that the client has perineal pain or a condition requiring a sitz bath.
E. Encourage prolonged dangling before ambulation. The client is already ambulating independently, indicating no significant issues with orthostatic hypotension or weakness. Encouraging prolonged dangling is unnecessary and could delay mobility, which is essential for preventing complications such as constipation and venous thromboembolism.
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