A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Assist the client to Fowler's position

Promote removal of pulmonary secretions

Increase the oxygen flow

Obtain a specimen for arterial blood gases

Answer and Explanation

The Correct Answer is A

A. Assist the client to Fowler's position: This position helps maximize lung expansion, making it easier for the client to breathe.
B. Promote removal of pulmonary secretions: Important but secondary to addressing immediate respiratory distress.
C. Increase the oxygen flow: This should only be done per provider order to avoid complications such as oxygen toxicity.
D. Obtain a specimen for arterial blood gases: This is a diagnostic step but not an immediate intervention for difficulty breathing.

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Correct Answer is D

Explanation

A) Took five quick "huffs" and then coughed vigorously. Huff coughing is a technique used to clear secretions, but it is not the correct method for using an incentive spirometer.
B) Exhaled deeply and then inhaled quickly and forcefully three times. Rapid inhalation and exhalation do not promote effective lung expansion or alveolar recruitment.
C) Took five deep breaths slowly every 4 hours. This frequency is insufficient to prevent atelectasis and postoperative lung complications.
D) Took 10 slow, deep breaths every hour. Taking 10 slow, deep breaths every hour encourages full lung expansion and prevents complications such as atelectasis.

A. Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck. B. Suction for 20 seconds. C. Clean secretions from the tube using hydrogen peroxide. D. Set the vacuum pressure at 120 mmHg for suctioning.

Correct Answer is D

Explanation

A) Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck. The ties should be secure but loose enough to fit one finger between the ties and the neck to prevent skin breakdown and maintain comfort.
B) Suction for 20 seconds. Suctioning for 20 seconds is too long and may cause hypoxia. Suction should not exceed 5 to 10 seconds.
C) Clean secretions from the tube using hydrogen peroxide. Hydrogen peroxide can irritate the delicate tissues and is not recommended. Saline or prescribed cleaning agents are preferred.
D) Set the vacuum pressure at 120 mmHg for suctioning. For a toddler, suction pressure should typically be between 80 and 120 mmHg to prevent mucosal damage.

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A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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