The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?
Measure the vital signs.
Assist to a high Fowler's position.
Initiate deep breathing exercises.
Auscultate breath sounds.
The Correct Answer is B
Rationale
A. Measuring vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, is important to assess the client's overall status and to determine the severity of the dyspnea. Vital signs provide essential information to guide further interventions. While important, this action may not directly alleviate the client's immediate distress from dyspnea.
B. Placing the client in a high Fowler's position (sitting upright with the head of the bed elevated to 90 degrees) helps to maximize chest expansion and improve lung ventilation. This position can relieve dyspnea by reducing pressure on the diaphragm and improving lung compliance. It is a simple and effective intervention for clients experiencing respiratory distress.
C. While deep breathing exercises are beneficial for promoting lung expansion and improving respiratory function, they may not be appropriate as the first action when the client is already dyspneic. The priority
should be to position the client to alleviate immediate breathing difficulty before initiating exercises that require active participation.
D. Auscultating breath sounds is important for assessing lung function and detecting any abnormalities such as adventitious sounds (e.g., crackles, wheezes). However, this action is secondary to placing the client in a high Fowler's position to relieve dyspnea. Auscultation can be performed after the client's breathing has stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. This finding suggests that the skin has already broken down, indicating a more advanced stage of pressure injury rather than an early indication. The presence of broken skin typically indicates at least a Stage 2 pressure injury according to the staging system.
B. This description suggests the presence of a deep tissue injury (DTI), which is a late sign of pressure injury.
C. This is indicative of a stage I pressure injury, where the skin is still intact but shows signs of redness that does not blanch with pressure. This stage precedes the actual breakdown of skin seen in more advanced pressure injuries.
D. This finding describes a superficial wound with clear margins, suggesting a Stage 2 pressure injury. It is more advanced than the early signs typically sought for early intervention.
Correct Answer is C
Explanation
Rationale
A. While it is important background information, it is not directly relevant to the acute change in the client's condition (increasing confusion and agitation). Therefore, this should not be provided first in the SBAR communication.
B. Knowing the client's current medications is important for understanding any potential causes or exacerbating factors related to the sudden onset of confusion and agitation. However, this is also background information and does not immediately address the acute change in the client's condition.
C. This is the most critical piece of information to provide first in the SBAR communication. Sudden onset of increasing confusion and agitation can indicate various urgent issues such as delirium, infection, metabolic disturbances, or neurological complications. This requires immediate attention and intervention from the healthcare provider.
D. While knowing the client's healthcare power of attorney is important for ensuring appropriate decision-making if needed, it is not urgent information in the context of reporting a sudden change in the client's condition. This can be discussed later in the SBAR communication or as part of the background information if relevant to the client's care.
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