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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

C. Raisins are a source of carbohydrates, particularly simple sugars like glucose and fructose, which can quickly raise blood sugar levels during an episode of hypoglycemia. However, they do not contain protein, which can help sustain blood sugar levels over time. Raisins may provide a rapid increase in blood sugar but may not be as effective at preventing subsequent episodes of hypoglycemia.
A. Cheese is a source of protein and contains very little carbohydrate. While protein can help stabilize blood sugar levels, it may not provide a rapid increase in blood sugar during an episode of hypoglycemia. Cheese alone may not be the most effective choice for treating low blood sugar promptly.
B. Beef jerky is primarily a source of protein and may not contain enough carbohydrates to quickly raise blood sugar levels during an episode of hypoglycemia. While protein can help stabilize blood sugar over time, it may not provide the rapid increase in blood sugar needed to address acute hypoglycemia.
D. Chocolate, especially dark chocolate with a high cocoa content, contains carbohydrates in the form of sugar and fat. While it can quickly raise blood sugar levels due to its sugar content, it may not provide sustained energy due to its low protein content.

A. A 35-year-old patient using the incentive spirometer following abdominal surgery B. A 55-year-old patient who is eating in the chair following a rhinoplasty C. A 40-year-old patient who refuses to cough and deep breath following a splenectomy D. A24-year-old patient ambulating in the hall following an appendectomy

Correct Answer is C

Explanation

C. This patient is at high risk for hospital-acquired pneumonia. After a splenectomy (removal of the spleen), patients may experience pain and discomfort, which can make them reluctant to perform necessary activities like coughing and deep breathing. These activities are crucial for preventing lung complications such as atelectasis and pneumonia.
A. This patient is actively using an incentive spirometer, which is a device that encourages deep breathing and helps keep the lungs clear. This practice significantly reduces the risk of developing pneumonia by preventing atelectasis (collapse of part of the lung) and promoting lung expansion.

B. This patient is out of bed and eating, which indicates they are relatively mobile and maintaining normal respiratory function. Rhinoplasty, a surgical procedure on the nose, generally does not impair lung function or significantly increase the risk of pneumonia. Being active and upright further reduces the risk of HAP.
D. This patient is actively ambulating, which is highly beneficial for lung function and overall recovery. Walking and moving around helps to prevent respiratory complications, including pneumonia, by promoting lung expansion and circulation.

View Question and Answer

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

The nurse enters a room of a patient who is acutely short of breath. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with newly diagnosed diabetes asks the nurse what to take for low blood sugar. Which of the following would be most appropriate for the nurse to suggest?

Correct Answer is C

Explanation

Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?

Correct Answer is C

Explanation

A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Gas exchange occurs in which of the following structures?

A nurse is collecting data from a client who has gastroesophageal reflux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client's heartburn?

A 33-year-old patient has pneumonia. When the nurse assesses this patient, which of the following data will receive the highest priority?

A patient is admitted to a respiratory unit with a diagnosis of bacterial pneumonia. Findings include a fever and a weak, congested-sounding cough with moist crackles throughout the lung fields. How should the nurse prioritize care?

The nurse is caring for a patient with pneumonia. Which lab abnormality is most concerning?

The nurse is assisting with nutrition teaching for a patient who voices concern over adjusting to a diabetic diet. Which response by the nurse about medical nutrition therapy is correct?