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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Dry mouth
Dry mouth is a common adverse effect of ipratropium (Atrovent) due to its anticholinergic properties. Anticholinergic medications can inhibit saliva production, leading to a sensation of dryness in the mouth. While uncomfortable, dry mouth tends to improve over time as the body adjusts to the medication. Patients can manage dry mouth by increasing fluid intake and practicing good oral hygiene.
B. Anxiety
Anxiety is not a common adverse effect of ipratropium (Atrovent). While some individuals may experience anxiety as a side effect of certain medications, it is not typically associated with ipratropium. If a patient experiences anxiety while taking ipratropium, it is essential to assess whether it may be related to other factors or medications and to consult a healthcare provider for appropriate management.
C. Tachycardia
Tachycardia (rapid heart rate) is not a common adverse effect of ipratropium (Atrovent). While ipratropium is an anticholinergic medication that can affect heart rate in some individuals, tachycardia is not typically reported as a common side effect. However, patients should be monitored for changes in heart rate and other cardiovascular effects while taking ipratropium, especially if they have pre-existing cardiac conditions.
D. Urine retention
Urinary retention is a potential adverse effect of ipratropium (Atrovent) due to its anticholinergic properties. Anticholinergic medications can relax the smooth muscle of the bladder, leading to difficulty emptying the bladder completely. However, urinary retention is less common with ipratropium compared to other anticholinergic medications, such as those used to treat overactive bladder. Patients experiencing urinary retention while taking ipratropium should consult their healthcare provider for further evaluation and management.
Correct Answer is B
Explanation
A. Metabolic acidosis
Metabolic acidosis is characterized by a low pH (< 7.35) and a decreased bicarbonate level (< 22 mEq/L). In this scenario, the pH is low (7.22), but the bicarbonate level is elevated (28 mEq/L), which does not support a diagnosis of metabolic acidosis.
B. Respiratory acidosis
Respiratory acidosis occurs when there is an accumulation of carbon dioxide (PaCO2 > 45 mm Hg), leading to a decrease in pH (< 7.35). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), consistent with respiratory acidosis.
C. Metabolic alkalosis
Metabolic alkalosis is characterized by a high pH (> 7.45) and an elevated bicarbonate level (> 26 mEq/L). In this scenario, the pH is low (7.22), and the bicarbonate level is also elevated (28 mEq/L), which does not support a diagnosis of metabolic alkalosis.
D. Respiratory alkalosis
Respiratory alkalosis occurs when there is a decrease in carbon dioxide (PaCO2 < 35 mm Hg), leading to an increase in pH (> 7.45). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), which is not consistent with respiratory alkalosis.
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