A patient is experiencing dyspnea.
Which intervention(s) would the nurse implement for the patient? Select all that apply.

Encourage the patient to use an incentive spirometer.

Auscultate lung sounds bilaterally.

Ambulate the patient in the hall.

Position the bed in high fowlers.

Assess the pulse oximetry.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale:

Encourage the patient to use an incentive spirometer. Rationale: Encouraging the use of an incentive spirometer helps improve lung function and prevent respiratory complications. It promotes deep breathing and prevents atelectasis, especially in patients experiencing dyspnea.

Choice B rationale:

Auscultate lung sounds bilaterally. Rationale: Auscultating lung sounds helps the nurse assess for abnormal breath sounds, such as wheezing or crackles, which can indicate respiratory distress. This assessment is crucial in managing a patient with dyspnea.

Choice C rationale:

Ambulate the patient in the hall. Rationale: Ambulating the patient can worsen dyspnea in some cases, especially if the patient is experiencing severe respiratory distress. Therefore, this intervention may not be appropriate for a patient with dyspnea.

Choice D rationale:

Position the bed in high fowlers. Rationale: Positioning the patient in high fowlers (sitting upright with the head of the bed elevated) helps improve lung expansion and ease breathing. This position maximizes the patient's lung capacity and can provide relief from dyspnea.

Choice E rationale:

Assess the pulse oximetry. Rationale: Monitoring pulse oximetry levels is essential in assessing the patient's oxygen saturation. It helps the nurse determine if the patient is receiving adequate oxygenation, which is crucial in managing dyspnea. A normal oxygen saturation range is typically 95% to 100%.

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Correct Answer is B

No explanation

A. Permit smoking in the home only if the patient is using low-flow oxygen. B. Place the oxygen tank in direct sunlight to keep it warm and humidified. C. Encourage the patient to use electric razors when wearing oxygen. D. Do not use electrical equipment near the oxygen administration set.

Correct Answer is D

Explanation

Choice A rationale:

Permitting smoking in the home, even with low-flow oxygen, is highly dangerous and increases the risk of fire. Oxygen supports combustion, and any open flames, including smoking materials, can lead to a catastrophic fire. Therefore, this option is incorrect and unsafe.

Choice B rationale:

Placing the oxygen tank in direct sunlight is not advisable. Oxygen tanks should be stored in cool, well-ventilated areas away from direct sunlight, heat sources, and flammable materials. Storing the tank in direct sunlight can increase the pressure inside the tank, potentially leading to leaks or ruptures.

Choice C rationale:

Encouraging the patient to use electric razors is a safe practice when wearing oxygen. Electric razors eliminate the risk of open flames, reducing the potential for accidents. This option promotes patient safety and is a suitable instruction for patients using oxygen at home.

Choice D rationale:

Not using electrical equipment near the oxygen administration set is crucial for patient safety. Electrical equipment can generate sparks, posing a significant fire hazard in the presence of oxygen. Instructing patients to keep electrical devices away from oxygen supplies helps prevent accidents and ensures a safe home environment for patients requiring oxygen therapy.

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A patient is experiencing dyspnea.Which intervention(s) would the nurse implement for the patient? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Which intervention(s) would the nurse implement for the patient? Select all that apply.