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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Start slowly and increase volume over several sessions: Gradually increasing lung volume improves compliance and helps clients build confidence with the device.
B. Be much more vigorous in increasing increments: Rapid or forceful attempts can cause hyperventilation or dizziness and are not recommended.
C. Do regular deep-breathing exercises instead: Deep breathing can be helpful but does not replace the targeted lung expansion benefits of the incentive spirometer.
D. Use another device because this one might be faulty: Device failure is rare; user education is usually more effective.
Correct Answer is ["A"]
Explanation
A. Incomplete expirations: Age-related decreased lung elasticity impairs full expiration, trapping air in the lungs.
B. Decreased oxygen saturation: Age-related changes in lung tissue reduce gas exchange efficiency.
C. Impaired cilia: Decreased ciliary function reduces the ability to clear mucus and pathogens from the airway.
D. Increased elasticity in thorax and respiratory tissues: Elasticity decreases with aging, reducing lung compliance.
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