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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: While all individuals can develop heart failure, an Asian male is not considered the highest risk group based on the available data.

Choice B reason: A Black female is at a higher risk for developing heart failure, especially due to factors like hypertension, diabetes, and certain socioeconomic factors³.

Choice C reason: A Hispanic female may have multiple risk factors for heart failure, but the prevalence and risk are not as high as in the Black female population³.

Choice D reason: A White male, while at risk for heart failure, does not have the highest risk when compared to a Black female with the same age and health conditions³.

A. "Oh, I'm so pleased that you finally put on clean clothes." B. "Why did you wear clean clothes and comb your hair today?" C. "I see that you have on clean clothes and have combed your hair." D. "That's good. You have on clean clothes and have combed your hair."

Correct Answer is C

Explanation

Choice A reason: This statement is not appropriate as it may sound condescending and does not acknowledge the client's effort in a respectful manner.

Choice B reason: This question could be perceived as intrusive and might make the client feel defensive about their self-care activities.

Choice C reason: This response is appropriate as it is a neutral observation that acknowledges the client's effort without making judgments or assumptions.

Choice D reason: While this statement is positive, it may not be the best choice as it could be interpreted as patronizing rather than a simple acknowledgment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a group of patients. Which patient is at the highest risk for developing heart failure (HF)?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

The nurse reinforces teaching to the patient on left heart failure (HF). The nurse would evaluate the patient as understanding if the patient stated which of these occurs to blood flow through the heart?

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