During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

Observe for jugular vein distention while the client is flat in bed.

Measure the client's blood pressure when he is lying and standing.

Ask the client how many pillows he sleeps on at night.

Auscultate the client's breath sounds while he is supine.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Observing for jugular vein distention while the client is flat in bed is incorrect because jugular vein distention is not directly related to orthopnea. Jugular vein distention may indicate increased central venous pressure, which can occur in conditions such as heart failure, but it is not specific to orthopnea, which is difficulty breathing while lying flat.
Choice B Reason:
Measuring the client's blood pressure when he is lying and standing is incorrect because measuring blood pressure in different positions (lying and standing) is used to assess for orthostatic hypotension, not orthopnea. Orthostatic hypotension refers to a drop-in blood pressure upon standing and is not directly related to difficulty breathing while lying flat.
Choice C Reason:
Asking the client how many pillows he sleeps on at night is correct because orthopnea is characterized by difficulty breathing while lying flat, often relieved by sitting up or propping oneself with pillows. Asking the client how many pillows he sleeps on at night provides valuable information about his sleeping position and potential orthopnea. Clients with orthopnea often need to sleep in a semi-upright position or with multiple pillows to alleviate breathing difficulties.
Choice D Reason:
Auscultating the client's breath sounds while he is supine is incorrect because auscultating the client's breath sounds while he is supine may provide information about lung sounds, but it does not specifically assess for orthopnea. Orthopnea refers to difficulty breathing while lying flat, and the assessment of breath sounds may not directly indicate this condition.

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Correct Answer is D

Explanation

Choice A Reason:
Audible thud without pain is incorrect. An audible thud without pain would not be an expected response when percussing the costovertebral angle (CVA) in a client with pyelonephritis. Pyelonephritis typically presents with tenderness upon percussion of the CVA due to inflammation or infection of the kidneys. The absence of pain in this scenario would not be consistent with the expected response.
Choice B Reason:
Rigidity and firmness are incorrect. Rigidity and firmness upon percussion of the costovertebral angle (CVA) may suggest muscle tension or guarding, rather than the tenderness typically associated with kidney inflammation or infection such as pyelonephritis. While guarding can occur in response to pain, it is not the expected response when assessing for kidney tenderness.
Choice C Reason:
Rebound tenderness is incorrect. Rebound tenderness refers to the exacerbation of pain upon release of pressure, typically observed in conditions such as peritonitis. While rebound tenderness may be present in some abdominal conditions, it is not the expected response when percussing the costovertebral angle (CVA) to assess for kidney tenderness in pyelonephritis. In pyelonephritis, tenderness upon initial percussion is more indicative of the condition.
Choice D Reason:
Sharp, severe pain is correct. Sharp, severe pain upon percussing the CVA suggests tenderness, which can be indicative of kidney inflammation or infection, such as pyelonephritis. This finding would support the diagnosis and help guide further assessment and treatment.

A. Splint the affected joint. B. Encourage fluid intake. C. Increase Intake of red meat. D. Measure urine output.

Correct Answer is B

Explanation

Choice A Reason:
Splint the affected joint is inappropriate action. While splinting may help stabilize the joint and reduce movement, it may not directly address the underlying cause of the symptoms, which is9levated uric acid levels leading to gout. Additionally, splinting may further restrict range of motion and exacerbate discomfort.
Choice B Reason:
Encouraging fluid intake is appropriate action. Encouraging fluid intake, particularly water, is beneficial for individuals experiencing a gout flare-up. Adequate hydration helps to dilute uric acid in the bloodstream and promote its excretion through urine, which can help alleviate symptoms and prevent further flare-ups. Therefore, option B is the most appropriate action for the nurse to advise the client in this situation.
Choice C Reason:
Increasing intake of red meat is inappropriate action. Red meat is high in purines, which can contribute to elevated uric acid levels and increase the risk of gout flare-ups. Therefore, increasing intake of red meat would not be advisable for someone experiencing gout symptoms. In fact, dietary modifications often involve reducing intake of purine-rich foods like red meat to help manage gout.
Choice D Reason:
Measuring urine output is inappropriate action. While monitoring urine output is important for overall hydration status, it may not be the most immediate or relevant action in this situation. The priority in managing a gout flare-up is to address the underlying cause by promoting uric acid excretion through adequate hydration, rather than solely focusing on measuring urine output.

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During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Correct Answer is D

Explanation

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Correct Answer is B

Explanation

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