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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

A lung biopsy is an invasive procedure that is typically performed to diagnose conditions such as lung cancer or interstitial lung disease. It is not the first-line test for evaluating increased shortness of breath in a client with COPD56.

Choice B rationale

Spirometry is a common, non-invasive test used to assess lung function and is particularly useful in conditions like COPD. It measures the volume and speed of air a person can inhale and exhale, which can help in assessing the severity of COPD56.

Choice C rationale

Antibody testing is typically used to diagnose conditions related to the immune system, such as allergies or autoimmune diseases. It is not typically used to evaluate shortness of breath in a client with COPD56.

Choice D rationale

A sweat test is used to diagnose cystic fibrosis by measuring the amount of salt in a person’s sweat. It is not used to evaluate shortness of breath in a client with COPD56.

A. Secure the room with padded walls and minimal furnishings. B. Release the client as soon as composure is regained. C. Provide one-on-one observation at all times. D. Observe for extrapyramidal symptoms, such as dystonia.

Correct Answer is D

Explanation

Choice A rationale

While securing the room with padded walls and minimal furnishings is an important aspect of seclusion, it is not the most important intervention immediately after seclusion. The safety of the client is paramount, and observing for extrapyramidal symptoms, such as dystonia, is crucial as haloperidol, an antipsychotic medication known to have the potential for causing extrapyramidal side effects, was administered.

Choice B rationale

Releasing the client as soon as composure is regained is not the most important intervention. The client’s mental and physical health needs to be continuously monitored, especially for side effects of the medication administered.

Choice C rationale

Providing one-on-one observation at all times is important, but it is not the most important intervention immediately after seclusion. The priority is to monitor for any adverse effects of the medication administered.

Choice D rationale

Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects.

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The nurse observes that a client with ascites is dyspneic.Which action should the nurse implement first?

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The nurse observes that a client with ascites is dyspneic.
Which action should the nurse implement first?