After change of shift, the nurse has the following patients on her assignment. Which one should she see first?

A 50-year-old with COPD and a Spo2 of 90%

A 72-year-old with pneumonia who needs his antibiotic

A 37-year-old with asthma who reported that he is still having shortness of breath after using his inhaler

A68-year-old on a CPAP who needs a sputum specimen sent to the lab

Answer and Explanation

The Correct Answer is C

C. Persistent shortness of breath after using an inhaler could indicate an inadequate response to treatment or worsening asthma exacerbation. The nurse should therefore see this patient first.
A. In COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable. In the treatment of exacerbations of chronic obstructive pulmonary disease (COPD), oxygen should be titrated to achieve a target oxygen saturation range of 88-92%. This results in a greater than twofold reduction in mortality, compared with the routine administration of high-concentration oxygen therapy.
B. Administering antibiotics can be prioritized, but it may not require immediate attention compared to addressing acute respiratory distress or hypoxemia.
D. Collecting a sputum specimen for laboratory analysis is important for diagnosing and managing respiratory infections, but it may not be as time-sensitive as addressing acute respiratory distress or hypoxemia.

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Correct Answer is C

Explanation

C. Pursed lip breathing is a technique that can help patients with acute dyspnea by improving ventilation, prolonging exhalation, and reducing the work of breathing. It helps to keep the airways open longer and makes it easier to get rid of excess carbon dioxide, which can provide quick relief from acute shortness of breath.
A. Teaching the patient about using accessory muscles for breathing can be beneficial in managing chronic respiratory issues, but it is not an immediate intervention.
B. Understanding the cause of dyspnea is important for treatment planning but it is not the first action to take when the patient is experiencing acute shortness of breath.
D. The Sims position, where the patient lies on their side with the lower arm behind the back and the upper leg flexed, is not typically used for relieving acute respiratory distress.

A. P 100 beats/minute B. R 20 breaths/minute C. BP 130/78 mm Hg D. Pain level of 6/10

Correct Answer is B

Explanation

B. A decrease in the respiratory rate from 32 breaths/minute to 20 breaths/minute indicates improved respiratory status and effectiveness of nursing care. A lower respiratory rate suggests that the patient's breathing is becoming less labored, and oxygenation may be improving.
A. A lower heart rate may suggest a reduction in pain, improved oxygenation, or decreased stress on the cardiovascular system. However, other factors such as medications, rest, and hydration can also influence heart rate. Overall, a decrease in heart rate is a favorable finding.
C. A slight decrease in blood pressure from 140/80 mm Hg to 130/78 mm Hg may indicate a positive response to nursing care. However, blood pressure fluctuations can be influenced by various factors, including hydration status, medications, and underlying medical conditions.
D. Pain management is an essential aspect of nursing care, particularly for patients with lower respiratory infections who may experience discomfort due to coughing, chest congestion, and inflammation. However, pain levels can fluctuate over time and may require ongoing assessment and intervention.

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After change of shift, the nurse has the following patients on her assignment. Which one should she see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse enters a room of a patient who is acutely short of breath. Which action should the nurse take first?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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