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 D

Explanation

Choice D rationale:

Adduction is the movement of a body part toward the midline of the body. When the nurse moves the patient's leg toward the midline of the patient's body, it is an adduction movement of the hip joint. This movement involves bringing the leg back to the body's midline, which is the opposite of abduction, where the leg moves away from the midline.

Choice A rationale:

Flexion refers to the bending of a joint, decreasing the angle between two body parts. This is not the correct term for moving the leg toward the midline; it describes a different movement.

Choice B rationale:

Abduction is the movement of a body part away from the midline of the body. It is the opposite movement to adduction. When the leg moves away from the midline, it is in abduction, not adduction.

Choice C rationale:

Extension refers to the straightening of a joint, increasing the angle between two body parts. It is the opposite movement to flexion. This movement does not involve bringing the leg toward the midline.

A. Activate the closest fire alarm/emergency response system. B. Provide emotional support to patients affected by the situation. C. Evacuate patients in the general area to a safe area. D. Remove any patients/staff from immediate danger. E. Close windows and doors in the area of fire.

Correct Answer is ["D","A","E","C","B"]

Explanation

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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

The nurse performs range of motion by moving the patient's leg toward the midline of the patient's body.This movement would be documented as what of the hip?

Correct Answer is D

Explanation

The nurse identifies the presence of a fire on the medical unit and responds to keep patients as safe as possible.Place the following nurse's actions in correct order by dragging them to the correct order.Use all 5 options.Drag by clicking on the dots.

Correct Answer is ["D","A","E","C","B"]

Explanation

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