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.

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Correct Answer is D

Explanation

A. Kleihauer-Betke test. This test is used to detect fetal-maternal hemorrhage by identifying fetal red blood cells in maternal circulation. It is not related to a nonreactive NST, which indicates the need for further fetal well-being assessment rather than checking for fetal-maternal bleeding.
B. Amnioinfusion. This procedure involves infusing fluid into the amniotic sac to relieve umbilical cord compression or dilute meconium-stained amniotic fluid. It is not an appropriate intervention for a nonreactive NST, as it does not assess fetal oxygenation or reactivity.
C. Administration of terbutaline. Terbutaline is a tocolytic used to relax the uterus and prevent preterm labor. It is not indicated for a nonreactive NST, as the concern in this scenario is fetal well-being rather than uterine activity.
D. Contraction stress test. A nonreactive NST means that the fetal heart rate does not demonstrate adequate accelerations, which can indicate potential fetal hypoxia. A contraction stress test is performed next to evaluate how the fetal heart rate responds to contractions, helping determine if the fetus can tolerate labor.

A. Trousseau's sign B. Irregular heart rate C. Hyperactive reflexes D. Dry mucous membranes

Correct Answer is B

Explanation

A. Trousseau's sign indicates hypocalcemia, not hyperkalemia. It is assessed by inflating a blood pressure cuff around the upper arm and observing for muscle spasms in the hand and wrist, which is not related to potassium levels.
B. Irregular heart rate. Hyperkalemia can lead to cardiac dysrhythmias due to its effect on myocardial excitability and conduction. Elevated potassium levels can cause changes in the electrocardiogram (ECG), such as peaked T waves and prolonged PR intervals, which may result in an irregular heart rate and can be life-threatening if not addressed.
C. Hyperactive reflexes are typically associated with conditions such as hypercalcemia or neurological disorders, not hyperkalemia. Hyperkalemia can lead to decreased neuromuscular excitability and may present with muscle weakness or decreased reflexes.
D. Dry mucous membranes is more indicative of dehydration or a fluid volume deficit rather than hyperkalemia. Clients with renal failure may have fluid retention and edema due to impaired kidney function, which is contrary to the presentation of dry mucous membranes.

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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 caring for a client who is at 36 weeks of gestation and is undergoing a nonstress test (NST). The test is nonreactive. Which of the following interventions should the nurse suggest based on the findings?

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

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