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. Perform tracheostomy care for the client every 4 hr: Tracheostomy care is performed based on the assessment of the need for cleaning and secretion management rather than a fixed time schedule.
B. Place the client in a lateral recumbent position prior to tracheostomy care: This position does not facilitate optimal visualization of the tracheostomy site. The Fowler's or semi-Fowler's position is preferred.
C. Clean the tracheostomy stoma with a chlorhexidine solution: Chlorhexidine is too harsh for mucosal surfaces and can cause irritation. Normal saline is recommended for cleaning.
D. Preoxygenate the client for 10 seconds prior to tracheostomy care: Preoxygenation for at least 30 to 60 seconds is recommended to prevent hypoxia during suctioning.

A. Toe B. Skin fold C. Earlobe D. Finger

Correct Answer is C

Explanation

A) Toe. Thickened toenails and edema make this site unreliable for accurate readings.
B) Skin fold. Skin folds are not recommended for pulse oximetry measurements due to poor contact and inconsistent readings.
C) Earlobe. The earlobe is a preferred site in cases of peripheral edema or thickened nails because it has good perfusion and provides reliable readings.
D) Finger. Edema in the hands compromises the accuracy of finger pulse oximetry measurements.

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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

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

Correct Answer is C

Explanation

The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is:

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