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.

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Correct Answer is ["B","D","E"]

Explanation

B. Bronchodilators are medications commonly used to relieve bronchospasm and improve airflow in patients with COPD. They work by relaxing the muscles around the airways, making it easier to breathe. Providing bronchodilators as prescribed can help alleviate difficulty breathing and improve the patient's respiratory function.
D. Smoking cessation is essential for patients with COPD as smoking is the leading cause of the disease and can exacerbate respiratory symptoms. Quitting smoking can slow the progression of COPD, reduce the frequency and severity of exacerbations, and improve overall lung function.
E. Corticosteroids are anti-inflammatory medications commonly used to reduce airway inflammation and control exacerbations in patients with COPD. They can help improve breathing and reduce the severity of respiratory symptoms during acute exacerbations.
A. Offering small frequent meals can help reduce the sensation of fullness and bloating, which can sometimes occur in patients with COPD due to increased abdominal pressure from compromised respiratory function. However, this is not specific to COPD.
C. Weaning from oxygen should be done cautiously and under the guidance of healthcare providers but not in the state of difficulty in breathing. Oxygen therapy is often necessary for patients with COPD who experience difficulty breathing, especially during acute exacerbations. Therefore, weaning from oxygen may be appropriate once the patient's respiratory status stabilizes and oxygen saturation levels improve.

A. presence of hiccups, amount of sweating BP B. capillary refill, amount of sputum, trembling C. size of pupil, presence of sneezing, location of pain D. restlessness, chest wall movement, color of nails

Correct Answer is D

Explanation

D. Restlessness can be an early sign of hypoxia. Chest wall movement provides information about the effort and effectiveness of breathing, and the color of the nails can indicate cyanosis, which is a sign of poor oxygenation. These data points are directly related to assessing respiratory status and the severity of pneumonia.

A. Hiccups, sweating, and blood pressure can provide useful information about the patient's condition, they do not directly indicate the severity of respiratory distress or oxygenation status. Hiccups can be a sign of diaphragmatic irritation, sweating can indicate fever or infection, and blood pressure is a general vital sign but not specific to respiratory function.
B. Capillary refill can provide information about peripheral perfusion, and the amount of sputum can be relevant to respiratory status, particularly in an infection like pneumonia. Trembling might indicate fever or anxiety but is less directly related to respiratory status compared to other signs.
C. Pupil size and sneezing are not directly related to respiratory function in pneumonia. Pain location could be relevant if it indicates pleuritic pain, but this set of data does not provide the most critical information for assessing respiratory function and oxygenation in a patient with pneumonia.

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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

The nurse is caring for a patient admitted with COPD, who is having difficulty breathing. Which actions can the nurse take to provide support? Select all that apply

Correct Answer is ["B","D","E"]

Explanation

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

Correct Answer is D

Explanation

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