A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?
Trendelenburg
Tripod
Supine
Low-Fowler's Position
The Correct Answer is B
A) Trendelenburg. This position involves tilting the patient with the head lower than the body and can worsen respiratory distress.
B) Tripod. The tripod position maximizes lung expansion by allowing the diaphragm to move freely, improving oxygenation.
C) Supine. The supine position can impair lung expansion and worsen respiratory distress.
D) Low-Fowler's Position. This position may provide minimal respiratory relief but is not as effective as the tripod position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Continue to monitor the client: A rise in the water seal with inspiration and fall during expiration (tidaling) is normal in a functioning chest tube system and indicates proper lung expansion.
B. Clamp the chest tube near the water seal: Clamping the tube can cause tension pneumothorax and is not appropriate unless specifically instructed by a provider.
C. Reposition the client and recheck the chamber: Repositioning is unnecessary unless there are signs of obstruction or complications.
D. Add water to the chamber: Water addition is only required if the water level falls below the recommended amount, not in response to normal tidaling.
Correct Answer is C
Explanation
A. Take a good nap: While rest is important, shallow breathing and irritability may indicate inadequate ventilation, which won't improve solely with sleep.
B. Turn, cough, and deep breathe: This helps open the airways, promotes alveolar expansion, and clears secretions, which may improve oxygenation and reduce restlessness.
C. Submit to a back rub: Although comforting, it does not directly address shallow breathing or improve oxygenation.
D. Take some pain medication: Pain control can be essential, but this action is premature without assessing whether pain is the cause of shallow breathing.
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