The nurse observes that a client with ascites is dyspneic.
Which action should the nurse implement first?
Auscultate breath sounds.
Measure the vital signs.
Assist to a high Fowler’s position.
Initiate deep breathing exercises.
The Correct Answer is C
Choice A rationale
While auscultating breath sounds is an important part of assessing a client’s respiratory status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.
Choice B rationale
While measuring vital signs is an important part of assessing a client’s overall status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.
Choice C rationale
Assisting the client to a high Fowler’s position can help alleviate dyspnea by allowing for greater lung expansion. This should be the nurse’s first action when a client with ascites is dyspneic.
Choice D rationale
While deep breathing exercises can help improve lung function and may be beneficial for a client with ascites, they are not the first action the nurse should take when the client is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Encouraging the client to drink at least 3 to 4 liters of water prior to the procedure is not a standard preparation for an intravenous pyelogram (IVP). Overhydration could potentially complicate the procedure.
Choice B rationale
It is essential for the nurse to notify the healthcare provider if the client reports any allergies to iodine or shellfish. The contrast dye used in an IVP often contains iodine. People who are allergic to iodine or shellfish may have a reaction to this dye.
Choice C rationale
Instructing the client to keep the legs straight for 6 to 8 hours after the procedure is not a standard instruction for IVP. This instruction is more commonly associated with procedures involving the insertion of a catheter into a large artery or vein.
Choice D rationale
Inserting an indwelling urinary catheter prior to going to the X-ray department is not a standard preparation for an IVP. The procedure involves the injection of a contrast dye into a vein, not the bladder.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
A rotator cuff injury could be a possibility given the patient’s age and the nature of the fall. The rotator cuff is a group of muscles and tendons that surround the shoulder joint, and injuries to this area are common in falls where the shoulder takes the impact.
Choice B rationale
A humeral fracture could also be a possibility. The humerus is the bone in the upper arm, and it can be fractured in falls, especially in older adults who may have weaker bones.
Choice C rationale
A concussion could be a possibility given that the patient hit his head on the wall. Symptoms of a concussion can include nausea and fatigue, which the patient is experiencing.
Choice D rationale
A knee sprain could be a possibility given that the patient is experiencing pain in his right knee. Sprains occur when the ligaments, which are the bands of tissue that hold bones together, are stretched or torn.
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