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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Use the arms to pick up heavy items. Lifting heavy objects using only the arms increases strain on the back, worsening pain. Pregnant clients should bend at the knees and lift with their legs while keeping the back straight to reduce stress on the lumbar region.
B. Raise chairs to keep knees lower than hips. Sitting with knees lower than the hips can worsen lumbar lordosis, increasing back discomfort. Instead, knees should be at or slightly above hip level to maintain spinal alignment and reduce strain on the lower back.
C. Perform pelvic rocking exercises several times per day. Pelvic rocking strengthens and stretches lower back muscles, improving flexibility and reducing discomfort. This exercise helps alleviate strain from the growing uterus and supports better posture, decreasing back pain.
D. Sit in a hot tub for 30 min every evening. Prolonged exposure to high temperatures, such as in a hot tub, can cause maternal hyperthermia, increasing the risk of fetal neural tube defects. Warm baths are a safer option to relieve muscle tension without harmful effects.

A. "I think you should find other family members who could help your mother." B. "Let me give you some information about respite care for your mother." C. "You should think about placing your mother in a long-term care facility." D. "You owe it to your mother to take care of her now that she needs you."

Correct Answer is B

Explanation

A. "I think you should find other family members who could help your mother." While involving other family members can be helpful, this response may come across as dismissive rather than supportive. The nurse should offer specific resources or interventions to assist with caregiver burden.
B. "Let me give you some information about respite care for your mother." Respite care provides temporary relief for caregivers by allowing trained professionals to care for the client. This helps reduce caregiver stress, prevents burnout, and allows the son to rest while ensuring his mother receives appropriate care.
C. "You should think about placing your mother in a long-term care facility." Suggesting placement in a facility without first assessing the son’s willingness or ability to continue caregiving may be inappropriate. The nurse should offer less drastic options, such as respite care, before discussing long-term placement.
D. "You owe it to your mother to take care of her now that she needs you." This statement could induce guilt and increase stress for the caregiver. The nurse should provide emotional support and resources rather than making the son feel obligated to provide care without assistance.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?

Correct Answer is C

Explanation

A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?

A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make?

A nurse is assisting with the care of a preschooler who is postoperative following an appendectomy. Exhibits Complete the following sentence by using the lists of options. The preschooler is at risk for developing dropdownevidenced by the preschooler'sdropdown

A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?

A nurse is collecting data from a client about range-of-motion for various joints. Which of the following images should the nurse identify as an example of a ball and socket joint? (IMAGES) A. B. C. D.