The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?
Avoid positioning the client supine.
Limit the client's activity level.
Administer supplemental oxygen at all times.
Teach the client deep breathing and coughing exercises.
The Correct Answer is A
A. Avoid positioning the client supine: Orthopnea is the inability to breathe comfortably while lying flat, so the nurse should avoid placing the client in a supine position and instead elevate the head of the bed.
B. Limit the client's activity level: While activity may need to be adjusted, this is not the primary concern for orthopnea.
C. Administer supplemental oxygen at all times: Oxygen may be necessary, but the key issue with orthopnea is the need to avoid lying flat, not necessarily the need for constant supplemental oxygen.
D. Teach the client deep breathing and coughing exercises: While beneficial for other conditions, this does not directly address orthopnea, which is primarily positional.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Decreases contractility: This is incorrect because ACE inhibitors do not directly affect myocardial contractility. They primarily work on the vascular system.
B. Increases preload: This is incorrect as ACE inhibitors do not increase preload. They may decrease preload by reducing fluid retention.
C. Decreased afterload: ACE inhibitors lower systemic vascular resistance (afterload) by inhibiting the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This reduces the workload on the heart.
D. Increases sympathetic stimulation: This is incorrect because ACE inhibitors actually reduce sympathetic stimulation by preventing the vasoconstrictive and sodium-retaining effects of angiotensin II.
Correct Answer is ["B","E"]
Explanation
A. Annual vitamin K injections: Vitamin K injections do not prevent Hepatitis B.
B. Use of standard precautions: Standard precautions reduce the risk of exposure to bloodborne pathogens, including Hepatitis B.
C. Consumption of a vitamin-rich diet: While a healthy diet is important, it does not specifically prevent Hepatitis B.
D. Annual vitamin B12 injections: Vitamin B12 injections are unrelated to Hepatitis B prevention.
E. Immunization: Vaccination is a key preventive measure against Hepatitis B.
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