Based on the information provided, what is the most appropriate initial nursing action?
Increase the oxygen flow rate.
Administer an additional dose of furosemide.
Notify the healthcare provider.
Reposition the client to a high Fowler’s position.
The Correct Answer is D
Choice A rationale:
Increasing the oxygen flow rate may help improve oxygen saturation, but it does not address the underlying issue of fluid overload and heart failure exacerbation.
Choice B rationale:
Administering an additional dose of furosemide may help reduce fluid overload, but it is not the most immediate action to improve the client’s respiratory status and comfort.
Choice C rationale:
Notifying the healthcare provider is important, but the nurse should first take immediate action to improve the client’s respiratory status and comfort.
Choice D rationale:
Repositioning the client to a high Fowler’s position is the most appropriate initial nursing action. This position helps improve lung expansion and reduces the work of breathing, providing immediate relief for the client experiencing dyspnea and respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Obtaining an influenza vaccine annually is crucial for individuals with type 1 diabetes mellitus. People with diabetes are at a higher risk of complications from infections, including influenza. The flu can lead to elevated blood sugar levels and potentially worsen diabetes control.
Therefore, getting the flu vaccine can help prevent or reduce the severity of the flu and its complications.
Choice B rationale
Administering glucagon is used for severe hypoglycemia, not hyperglycemia. Glucagon is a hormone that raises blood glucose levels by stimulating the liver to release stored glucose. It is typically used in emergency situations when a person with diabetes has very low blood sugar and is unable to consume sugar orally.
Choice C rationale
Insulin should be injected into subcutaneous tissue, not the deltoid muscle. The preferred injection sites for insulin are areas with more subcutaneous fat, such as the abdomen, thighs, buttocks, and upper arms. Injecting insulin into muscle tissue can lead to faster absorption and unpredictable blood glucose levels.
Choice D rationale
Glyburide is an oral medication used to treat type 2 diabetes, not type 1 diabetes. Type 1 diabetes requires insulin therapy because the body does not produce insulin. Glyburide works by stimulating the pancreas to release more insulin, which is not effective for individuals with type 1 diabetes who have little to no insulin production.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Notifying the health care provider immediately may be necessary if the bleeding is severe or persistent. However, in the case of small amounts of blood, it is important to continue assessing for bleeding to determine if the situation worsens. Immediate notification may not be necessary for minor bleeding.
Choice B rationale
Continuing to assess for bleeding is the best intervention for a child spitting up small amounts of blood after a tonsillectomy. This allows the nurse to monitor the situation and determine if the bleeding is worsening or if it resolves on its own. It is important to keep the child calm and avoid any actions that could exacerbate the bleeding.
Choice C rationale
Encouraging the child to cough can increase the risk of further bleeding. Coughing can dislodge clots and cause additional trauma to the surgical site. It is important to keep the child calm and avoid actions that could worsen the bleeding.
Choice D rationale
Suctioning the back of the throat can cause additional trauma to the surgical site and increase the risk of bleeding. It is important to avoid invasive procedures and continue to assess for bleeding. If the bleeding worsens, further medical intervention may be necessary.
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