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 D
Explanation
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.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
The apex of the heart (apical pulse) is the preferred site for assessing the heart rate in infants. It is located at the point of maximal impulse (PMI) and provides the most accurate measurement of the heart rate in this age group.
Choice B rationale
The brachial artery is not the preferred site for assessing the heart rate in infants. While it can be used for blood pressure measurement, it is not as accurate as the apical pulse for heart rate assessment.
Choice C rationale
The radial artery is not typically used for assessing the heart rate in infants. It is more commonly used in older children and adults.
Choice D rationale
The carotid artery is not recommended for assessing the heart rate in infants due to the risk of compressing the airway and causing discomfort.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.