A nurse enters a client's room to administer medication and finds the client lying in bed disoriented with labored and fast respirations. Which of the following actions should the nurse take first?

Prepare the client for endotracheal suctioning.

Elevate the head of the bed.

Request a chest x-ray.

Obtain a sputum culture.

Answer and Explanation

The Correct Answer is B

A. Prepare the client for endotracheal suctioning.

Endotracheal suctioning is a procedure used to clear secretions from the airway, which may be necessary in cases of respiratory distress. However, it is not the first action to take in this scenario. Before proceeding with suctioning, the nurse should first assess the client's respiratory status and implement interventions to improve ventilation and oxygenation.

B. Elevate the head of the bed.

This is the correct action to take first. Elevating the head of the bed helps improve the client's respiratory mechanics by allowing better lung expansion and reducing the work of breathing. It also helps alleviate symptoms of respiratory distress. This intervention should be implemented immediately to optimize the client's breathing.

C. Request a chest x-ray.

While a chest x-ray may provide valuable information about the client's respiratory status, it is not the first action to take in this acute situation. Chest x-rays require time to be performed and interpreted, which may delay necessary interventions to address the client's immediate respiratory distress.

D. Obtain a sputum culture.

Obtaining a sputum culture may be indicated to identify the underlying cause of respiratory distress, such as infection. However, it is not the first action to take when the client is experiencing acute respiratory distress. The priority is to implement interventions to improve ventilation and oxygenation to stabilize the client's condition.

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Correct Answer is D

Explanation

A. Spoon nails

Spoon nails, also known as koilonychia, refer to a concave or spoon-shaped deformity of the nails. This finding is associated with conditions such as iron deficiency anemia or certain systemic diseases, but it is not specifically associated with COPD.

B. Peripheral edema

Peripheral edema, or swelling of the extremities, is not a typical finding in COPD. It may occur in conditions such as heart failure, liver disease, or kidney disease, but it is not directly related to COPD unless there are comorbid conditions contributing to fluid retention.

C. Pleural friction rub

Pleural friction rub refers to a creaking or grating sound heard on auscultation of the lungs, typically during inspiration and expiration. It occurs when the inflamed pleural surfaces rub against each other. While pleural effusion (accumulation of fluid in the pleural space) may occur as a complication of COPD, pleural friction rub is not a typical finding in uncomplicated COPD.

D. Barrel chest

Barrel chest is a common finding in clients with COPD. It refers to an increased anterior-posterior diameter of the chest, giving it a rounded appearance similar to that of a barrel. This occurs due to hyperinflation of the lungs, which is characteristic of COPD, particularly in advanced stages. The hyperinflation leads to chronic air trapping and increased residual volume in the lungs, causing the chest to become enlarged and rounded.

A. "I'll rinse my mouth after taking this medication." B. "I'll use this medication when I get an asthma attack." C. "I'll take this medication once a day in the evening." D. "I'll decrease my sodium intake while I'm taking this medication."

Correct Answer is C

Explanation

A. "I'll rinse my mouth after taking this medication."

Montelukast is taken orally and is not associated with the risk of oral thrush or other mouth-related side effects that would require rinsing the mouth after administration. This action is more commonly associated with inhaled corticosteroids, not leukotriene receptor antagonists.

B. "I'll use this medication when I get an asthma attack."

Montelukast is not a rescue medication for asthma attacks. It is a long-term controller medication used to manage and prevent asthma symptoms, not to treat acute attacks. Short-acting bronchodilators such as albuterol are used for quick relief during asthma attacks.

C. "I'll take this medication once a day in the evening."

Montelukast is a leukotriene receptor antagonist commonly used to manage asthma. It is typically taken orally once daily, usually in the evening, to provide 24-hour control of asthma symptoms and improve lung function. Therefore, the statement indicating an understanding of the teaching is option C.

D. "I'll decrease my sodium intake while I'm taking this medication."

Montelukast is not known to affect sodium levels in the body or require any specific dietary modifications, such as decreasing sodium intake. Therefore, this statement is unrelated to the use of montelukast for asthma management

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A nurse enters a client's room to administer medication and finds the client lying in bed disoriented with labored and fast respirations. Which of the following actions should the nurse take first?

Nursing Test Bank

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