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. Ask a family member to interpret what the client is trying to communicate: While family members can sometimes help, the nurse should directly facilitate communication with the client using appropriate tools.
B. Ask the physician to wean the client off the mechanical ventilator to allow the client to talk: Weaning off a ventilator should only be done based on medical stability, not solely for communication purposes.
C. Ask the client to write, use a picture board, or spell words with an alphabet board: These tools can help non-verbal clients on mechanical ventilation express themselves and reduce frustration.
D. Assure the client that everything will be all right and that he shouldn't become upset: This response is dismissive and does not address the client's need to communicate.
Correct Answer is B
Explanation
A. Imbalanced nutrition: Less than body requirements related to decreased oral intake: While this may be relevant, it is not the highest priority in acute appendicitis. Infection prevention is more critical.
B. Risk for infection related to possible rupture of appendix: The primary concern in appendicitis is the risk of rupture, leading to peritonitis and sepsis. This makes infection control the top priority.
C. Chronic pain related to appendicitis: Pain in appendicitis is acute, not chronic. Managing infection risk is more urgent.
D. Constipation related to decreased bowel motility and decreased fluid intake: Constipation is not a priority concern in the context of acute appendicitis. The risk of infection takes precedence.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.