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 A

Explanation

A. Oral mucosa:

The oral mucosa, including the inside of the mouth, tongue, and lips, is a reliable indicator of cyanosis. Cyanosis appears as a bluish discoloration of these tissues due to decreased oxygen saturation in the arterial blood. Assessing the oral mucosa is an essential component of clinical examination, especially in patients with respiratory conditions like asthma, as it provides valuable information about oxygenation status.

B. Tip of the nose:

While the tip of the nose may exhibit cyanosis in some cases, it is not considered as reliable of an indicator as the oral mucosa. The nasal tip is more susceptible to external factors such as cold temperatures or poor circulation, which can cause temporary discoloration. Therefore, it may not always accurately reflect the oxygenation status of the patient compared to the oral mucosa.

C. Ear lobes:

Cyanosis may be observed in the ear lobes in cases of severe hypoxemia, but it is not as reliable of an indicator as the oral mucosa. The ear lobes are less commonly assessed for cyanosis compared to other areas such as the lips, nail beds, or oral mucosa. While cyanosis may be present in the ear lobes, it is not typically the primary site assessed for oxygenation status.

D. Eyelids:

Cyanosis is not typically observed in the eyelids and is not considered a reliable indicator of hypoxemia. The eyelids are not commonly assessed for cyanosis during clinical examinations. While the conjunctiva (the lining inside the eyelids) may appear pale in cases of severe anemia, it is not a specific sign of hypoxemia. Assessment of the oral mucosa, lips, and nail beds is preferred for evaluating oxygenation status in patients with respiratory conditions like asthma.

A. Acute bronchospasm B. Acute allergies C. Nasal congestion D. Dyspnea on exertion

Correct Answer is A

Explanation

A. Acute bronchospasm:

Albuterol (Proventil) is commonly used to treat acute bronchospasm, which is characterized by sudden constriction of the muscles surrounding the airways. This constriction leads to narrowing of the air passages, making it difficult to breathe. Albuterol works as a bronchodilator by relaxing these muscles, thereby opening up the airways and relieving symptoms such as wheezing, shortness of breath, and chest tightness. It is commonly used to manage conditions such as asthma, chronic obstructive pulmonary disease (COPD), and bronchitis, where bronchospasm is a prominent feature.

B. Acute allergies:

Albuterol (Proventil) is not typically used to treat acute allergies. While it can help alleviate symptoms such as wheezing and shortness of breath that may occur as a result of allergic reactions affecting the airways, its primary indication is for bronchospasm associated with respiratory conditions like asthma and COPD. Antihistamines and corticosteroids are more commonly used to manage allergic reactions and their associated symptoms.

C. Nasal congestion:

Albuterol (Proventil) is not indicated for the treatment of nasal congestion. Nasal congestion primarily involves swelling and inflammation of the nasal passages, which are not directly affected by albuterol. Decongestants such as pseudoephedrine or nasal corticosteroids are typically used to relieve nasal congestion by reducing inflammation and swelling in the nasal passages.

D. Dyspnea on exertion:

Albuterol (Proventil) may help alleviate dyspnea (shortness of breath) on exertion, particularly if it is caused by bronchospasm or exercise-induced bronchoconstriction. By relaxing the muscles around the airways, albuterol can improve airflow and ease breathing difficulties associated with exertion. However, it is important to note that albuterol is primarily indicated for the treatment of acute bronchospasm rather than dyspnea on exertion unrelated to bronchospasm. Other interventions, such as oxygen therapy or addressing underlying cardiovascular conditions, may be necessary to manage dyspnea on exertion in those cases.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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