At midnight, an older male client with heart failure who is receiving 02 at 4 L/minute suddenly awakens with dyspnea. The nurse determines that he has audible rhonchi, tachycardia, and is cold and clammy. Which action should the nurse implement first?

Encourage deep breathing and coughing.

Provide emotional support to alleviate anxiety.

Insert an indwelling urinary catheter.

Place the client in high-Fowler's position.

Answer and Explanation

The Correct Answer is D

A. Encourage deep breathing and coughing: While deep breathing can help mobilize secretions, this client is in acute respiratory distress and likely experiencing pulmonary edema. He may be too compromised to perform these exercises effectively until his breathing is stabilized.

B. Provide emotional support to alleviate anxiety: Emotional support is important but not priority when physical symptoms such as dyspnea, tachycardia, and cold, clammy skin signal acute decompensation. Physiologic stabilization must occur before psychological needs.

C. Insert an indwelling urinary catheter: Monitoring fluid output is relevant in managing heart failure, but inserting a catheter does not address the client's immediate respiratory distress. This intervention can be performed after the client's breathing is supported.

D. Place the client in high-Fowler’s position: High-Fowler’s position improves lung expansion and decreases preload by promoting venous pooling in the lower extremities, thus reducing pulmonary congestion. It is the most immediate and effective non-invasive intervention for relieving acute dyspnea.

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Correct Answer is A

Explanation

A. Prepare the client for surgery: The ABG shows compensated respiratory acidosis: pH is normal but on the low end, PaCO₂ is elevated, and HCO₃⁻ is normal on the higher end indicating renal compensation. This is a common pattern in stable COPD and does not contraindicate surgery. The client is medically optimized for the planned procedure.

B. Insert additional IV catheter: While IV access is necessary for surgical preparation, inserting an additional catheter is not directly related to the ABG findings. This action would only be needed if clinically indicated for fluid management or multiple infusions.

C. Obtain sputum specimen: A sputum specimen may be indicated if the client shows signs of respiratory infection or increased secretions, but the ABG does not reflect an acute infectious process.

D. Administer PRN bronchodilator: There’s no indication of acute bronchospasm or worsening airway obstruction. The ABGs reflect chronic compensation, not acute respiratory distress, so administering a bronchodilator based solely on these findings is unnecessary.

A. A description of the chest pain when client is at rest. B. A demonstration of the activity that precipitates pain. C. A complete seven (7) day diet history of client's oral intake. D. The client's blood pressures sitting and standing.

Correct Answer is A

Explanation

A. A description of the chest pain when client is at rest: Determining whether the pain occurs at rest helps differentiate stable from unstable angina. Stable angina typically resolves with rest and is exertion-related, while pain at rest may suggest unstable angina.

B. A demonstration of the activity that precipitates pain: While understanding what provokes the pain is helpful, a physical demonstration is unnecessary and potentially dangerous, especially if it might trigger another anginal episode.

C. A complete seven (7) day diet history of client's oral intake: Dietary intake is not immediately relevant for evaluating recent angina symptoms. Priority should be placed on identifying acute features that may signal unstable angina or myocardial infarction.

D. The client’s blood pressures sitting and standing: Assessing for orthostatic hypotension is useful in evaluating dizziness or syncope but does not directly address the nature or severity of chest pain. It is not the priority assessment for symptoms of angina pectoris following exertion.

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At midnight, an older male client with heart failure who is receiving 02 at 4 L/minute suddenly awakens with dyspnea. The nurse determines that he has audible rhonchi, tachycardia, and is cold and clammy. Which action should the nurse implement first?

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Correct Answer is A

Explanation

The nurse at a primary healthcare provider's (HCPs) office is assessing a middle aged client who describes having symptoms of angina pectoris that occured while doing yard work. Which additional finding should the nurse obtain?

Correct Answer is A

Explanation

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The nurse is assessing a hospitalized client with pulmonary edema who is reporting two pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse observes rapid shallow respirations and use of accessory muscles. Which action should the nurse include in the client's plan of care?