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.
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Related Questions
Correct Answer is B
Explanation
B. The inability to clear the airway is a critical issue. This patient has a weak, congested-sounding cough and moist crackles, indicating that secretions are present and not being effectively cleared. This can lead to airway obstruction, decreased oxygenation, and further respiratory complications. Clearing the airway is a top priority to ensure the patient can breathe properly and prevent further deterioration.
A. Difficulty breathing (dyspnea) is a serious concern as it can indicate respiratory distress or failure. However, it is often a symptom rather than a primary issue, and its underlying causes (such as an inability to clear the airway or inadequate oxygen levels) must be addressed first.
C. Confusion can result from high fever, infection, or hypoxia. While it is important to address the fever and its underlying cause, confusion itself is usually a secondary issue. Addressing the primary respiratory issues will often improve the patient's mental status as well.
D. Hypoxia can result from severe pneumonia, and resolving it involves ensuring the patient has a clear airway and adequate ventilation. Measuring and correcting oxygen levels (e.g., with supplemental oxygen) is crucial, but the underlying cause (such as airway obstruction) must also be managed.
Correct Answer is ["B","C","D","E"]
Explanation
B. Beta-blocking medications, such as propranolol and metoprolol, can worsen asthma symptoms in some individuals by constricting the airways. Patients with asthma should avoid or use caution with beta-blockers, especially non-selective ones, as they can trigger or exacerbate asthma attacks.
C. Exposure to secondhand smoke is a well-established trigger for asthma symptoms and can exacerbate respiratory inflammation and airway hyperresponsiveness. Patients with asthma should avoid exposure to secondhand smoke whenever possible to reduce the risk of asthma exacerbations.
D. Carpeting and drapes can harbor dust mites, pet dander, and other allergens that can trigger asthma symptoms in susceptible individuals. Patients with asthma may benefit from removing carpeting and minimizing soft furnishings in the bedroom to reduce exposure to allergens and improve air quality.
E. Pets, particularly those with fur or feathers, can be potent allergens for individuals with asthma. Patients with asthma should consider removing pets from the home or at least keeping them out of the bedroom to minimize exposure to pet dander.
A. Cardiovascular exercise can trigger asthma symptoms in some individuals but it is not typically recommended to eliminate exercise altogether. Instead, patients with asthma should be encouraged to engage in physical activities that are well-tolerated and to use appropriate preventive measures, such as pre-exercise bronchodilator therapy and warm-up exercises, to minimize symptoms.
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