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 A
Explanation
A. Pulmonary crackles/rales: Left-sided heart failure leads to a buildup of fluid in the lungs, causing pulmonary congestion and crackles/rales on auscultation.
B. Weight gain: This is more commonly associated with right-sided heart failure due to fluid retention, though it can be seen in both types of heart failure.
C. Hepatomegaly: Hepatomegaly is typically associated with right-sided heart failure due to congestion in the systemic circulation.
D. Jugular vein distention: JVD is a sign of right-sided heart failure, as it indicates increased central venous pressure.
Correct Answer is ["B","C","D"]
Explanation
A. Instruct the patient to lie on the Left side: The patient should lie on their right side (the biopsy side) to apply pressure and prevent bleeding.
B. Assess the patient's vital signs: Monitoring vital signs is crucial to detect signs of bleeding, hypovolemia, or shock.
C. Assess the dressing over the puncture site: Checking for bleeding or hematoma formation at the puncture site is important to detect complications.
D. Assess for signs/symptoms of a pneumothorax: A pneumothorax is a possible complication of liver biopsy, especially if the biopsy needle punctures the lung.
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