The nurse enters a room of a patient who is acutely short of breath. Which action should the nurse take first?
teach the patient the use of accessory muscles
ask the patient what caused the dyspnea
encourage the use of pursed lip breathing
assist the patient into a Sims position
The Correct Answer is C
C. Pursed lip breathing is a technique that can help patients with acute dyspnea by improving ventilation, prolonging exhalation, and reducing the work of breathing. It helps to keep the airways open longer and makes it easier to get rid of excess carbon dioxide, which can provide quick relief from acute shortness of breath.
A. Teaching the patient about using accessory muscles for breathing can be beneficial in managing chronic respiratory issues, but it is not an immediate intervention.
B. Understanding the cause of dyspnea is important for treatment planning but it is not the first action to take when the patient is experiencing acute shortness of breath.
D. The Sims position, where the patient lies on their side with the lower arm behind the back and the upper leg flexed, is not typically used for relieving acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This range is generally considered acceptable for most patients with COPD. It provides a balance between ensuring adequate oxygenation while avoiding the risk of oxygen toxicity. Oxygen saturation levels within this range can help alleviate symptoms of hypoxemia without causing hyperoxia.
B. Oxygen saturation levels below 90% can lead to significant hypoxemia and exacerbate respiratory distress in individuals with COPD. Maintaining oxygen saturation levels above 90% is typically recommended to prevent complications associated with hypoxemia.
C. This range is appropriate for some patients but it may not be ideal for all patients with COPD. Oxygen saturation levels at the higher end of this range (e.g., 100%) can increase the risk of oxygen toxicity in patients with COPD who retain carbon dioxide (CO2) due to their chronic respiratory condition.
D. Oxygen saturation levels within this range help to balance the need for oxygen supplementation with the risk of hyperoxia and oxygen toxicity. However, individual patient factors, such as the severity of COPD, baseline oxygen saturation levels, and comorbidities, should be considered when determining the target range for oxygen saturation.
Correct Answer is C
Explanation
C. Monitoring blood sugar levels regularly, as recommended by the doctor, is crucial for managing type 2 diabetes effectively. It helps patients track their glucose levels, identify patterns, and make informed decisions about medication, diet, and lifestyle choices to maintain optimal blood sugar control.
A. Drinking orange juice to treat high blood sugar is not recommended because it can cause a rapid increase in blood sugar levels due to its high sugar content. Instead, patients should focus on consuming foods or beverages with lower glycemic index values and more stable glucose responses.
B. Regular physical activity is an essential component of diabetes management as it helps improve insulin sensitivity, lower blood sugar levels, control weight, and reduce the risk of complications. Patients with diabetes are encouraged to engage in regular exercise as part of their overall treatment plan.
D. Eating a diet high in carbohydrates can lead to spikes in blood sugar levels, which can be detrimental for individuals with type 2 diabetes. Instead, patients are encouraged to follow a balanced diet that includes a variety of nutrient-rich foods, with a focus on whole grains, lean proteins, healthy fats, fruits, and vegetables, while moderating carbohydrate intake.
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