A patient hospitalized with a myocardial infarction suddenly begins having severe respiratory distress with frothy red sputum. What is the first action for the nurse to take?
Notify the patient's family.
Provide oxygen as prescribed.
Notify the health care provider.
Elevate the head of the bed.
The Correct Answer is B
Choice A Reason:Notifying the patient's family is not the immediate priority when the patient is experiencing severe respiratory distress. The nurse's primary focus should be on addressing the patient's acute symptoms.
Choice B Reason:Providing oxygen is crucial in managing respiratory distress. In a patient with myocardial infarction (heart attack), adequate oxygenation is essential to prevent further complications. The nurse should promptly administer oxygen as prescribed to improve oxygen supply and alleviate distress.
Choice C Reason:While notifying the health care provider is essential, it is not the first action in this critical situation. The nurse should prioritize interventions that directly address the patient's distress.
Choice D Reason:Elevating the head of the bed (semi-Fowler's position) is beneficial for patients with respiratory distress, but it is not the initial action. Providing oxygen takes precedence over positioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Reducing saturated fats, which are found primarily in red meat and full-fat dairy products, can lower low-density lipoprotein (LDL) cholesterol — the "bad" cholesterol.
Choice B reason: Avoiding trans fats is crucial as they increase LDL cholesterol and decrease high-density lipoprotein (HDL) cholesterol — the "good" cholesterol.
Choice C reason: Consuming whole grains is beneficial for lowering cholesterol because they contain soluble fiber, which can reduce the absorption of cholesterol into the bloodstream⁶.
Choice D reason: Limiting sugar-sweetened beverages can help reduce cholesterol levels, as excessive sugar intake can lead to weight gain, which is a risk factor for high cholesterol.
Choice E reason: Drinking whole milk is not recommended for cholesterol control as it contains high levels of saturated fat, which can raise cholesterol levels.
Choice F reason: Limiting fruit intake is not necessary for cholesterol control; in fact, fruits can be beneficial due to their fiber content⁶.
Correct Answer is C
Explanation
Choice A reason: While hostility and sarcasm can be challenging, they are not immediate safety concerns compared to the physical activity that could lead to exhaustion or injury.
Choice B reason: Giving away personal items and money can be concerning for the client's financial well-being, but it does not pose an immediate risk to their physical health.
Choice C reason: Pacing in the hallway during the day and most of the night could indicate a high level of psychomotor agitation associated with mania, which can lead to physical exhaustion or injury and is therefore a priority.
Choice D reason: Flight of ideas is a symptom of mania that, while important to note, does not pose an immediate risk to the client's safety like excessive physical activity does.
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