In which position would the nurse place a 20 year old adult with asthma who is short of breath?

Supine

Trendelenberg

High-Fowler

Semi-Fowler

Left-lateral

Answer and Explanation

The Correct Answer is C

A. Supine is not recommended, as it can make breathing more difficult by limiting chest expansion.
B. Trendelenberg is not suitable for someone with breathing difficulties, as this position can worsen dyspnea.
C. High-Fowler is the best position for an asthma patient experiencing shortness of breath as it promotes lung expansion and allows for maximum chest wall movement.
D. Semi-Fowler may help but is less effective than High-Fowler in cases of acute respiratory distress.
E. Left-lateral does not optimize chest expansion and is not typically recommended for respiratory distress.

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Correct Answer is A

Explanation

A. A heave (or lift) often indicates ventricular hypertrophy or enlargement, suggesting increased workload on the heart.
B. Turbulent blood flow may lead to murmurs but is not specifically associated with a heave.
C. A persistently slow heartbeat is referred to as bradycardia and does not correlate with a heave.
D. An extreme pulse deficit relates to discrepancies between heartbeats and palpable pulses but is not linked to a heave.
E. Coronary artery blockage would not directly produce a heave; it typically leads to ischemic changes.

A. Call another nurse for help B. Give pain medication as ordered C. Call the admitting healthcare provider D. Tell client to remain calm E. Apply oxygen via nasal cannula as ordered

Correct Answer is E

Explanation

A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.
B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.
C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.
D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.
E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.

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In which position would the nurse place a 20 year old adult with asthma who is short of breath?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a focused cardiac assessment on a newly admitted client, the nurse notes a heave on the left side of the chest. What can a heave signify?

Correct Answer is A

Explanation

A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

Correct Answer is E

Explanation

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