The practical nurse (PN) is monitoring a client who was admitted following a motor vehicle collision (MVC). The PN is unable to auscultate breath sounds on the left side, and the healthcare provider is notified. While awaiting the arrival of the healthcare provider, which action should the PN take?
Demonstrate the use of an incentive spirometer.
Monitor the client for increasing respiratory distress.
Administer a PRN dose of a diuretic medication.
Encourage the client to use pursed-lip breathing.
The Correct Answer is B
Choice A reason: Demonstrating the use of an incentive spirometer is a valuable intervention for encouraging deep breathing and preventing atelectasis. However, in the context of a client with absent breath sounds on one side, the priority is to monitor for signs of respiratory distress or complications such as a pneumothorax. While using an incentive spirometer may be beneficial in other scenarios, it is not the immediate priority in this case.
Choice B reason: Monitoring the client for increasing respiratory distress is the most critical action to take. The absence of breath sounds on the left side could indicate a serious complication such as a pneumothorax, hemothorax, or other issues that can compromise respiratory function. By closely monitoring the client, the practical nurse can detect signs of worsening condition, such as increased work of breathing, cyanosis, or changes in vital signs, and provide timely intervention or support while awaiting the healthcare provider's arrival.
Choice C reason: Administering a PRN dose of a diuretic medication is not appropriate in this context. Diuretics are used to manage fluid balance and treat conditions such as heart failure or hypertension but are not relevant for addressing the immediate concern of absent breath sounds and potential respiratory distress. The focus should remain on monitoring the client's respiratory status and ensuring appropriate interventions are available if needed.
Choice D reason: Encouraging the client to use pursed-lip breathing can be beneficial for clients experiencing shortness of breath or for managing chronic obstructive pulmonary disease (COPD). However, in the case of absent breath sounds on one side, it is more important to monitor for signs of respiratory compromise and ensure the client receives prompt medical evaluation and intervention. Pursed-lip breathing is not the immediate priority in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: There is no specific requirement to avoid upper body exercise on the day of a mammogram. While vigorous exercise might cause some temporary muscle discomfort, it does not impact the results of the mammogram. The primary concern is ensuring clear imaging of the breast tissue, not the effects of exercise.
Choice B reason: Clients are instructed not to use underarm deodorant on the day of a mammogram because deodorants, antiperspirants, powders, or lotions can contain metallic particles that may appear on the mammogram images as white spots. These spots can be mistaken for calcifications, leading to potential misinterpretation of the results or the need for additional imaging. Ensuring the client avoids using these products helps achieve the clearest possible images for accurate diagnosis.
Choice C reason: Avoiding aspirin for one week prior to a mammogram is not a standard instruction. Aspirin can affect blood clotting, and such instructions are typically given before surgical procedures rather than imaging tests. There is no direct impact of aspirin on the mammogram process or results.
Choice D reason: There is no requirement to avoid eating or drinking for 6 hours before a mammogram. This instruction is more relevant for procedures that involve anesthesia or sedation, where an empty stomach is necessary to reduce the risk of aspiration. Mammograms do not involve these risks, and clients can eat and drink as usual.
Correct Answer is D
Explanation
Choice A reason: Initiating contact isolation precautions is not necessary for psoriasis. Psoriasis is a non-infectious and non-contagious chronic skin condition, so isolating the client would not be appropriate. The main focus should be on managing the symptoms and providing the client with strategies to alleviate their discomfort and improve their quality of life.
Choice B reason: Explaining the need to keep the affected areas dry is not suitable for managing psoriasis. In fact, keeping the skin hydrated is crucial in managing psoriasis symptoms. Dry skin can exacerbate the condition, leading to increased flaking, itching, and discomfort. The practical nurse should educate the client on proper skin care, including using moisturizers to keep the skin hydrated and avoiding harsh soaps and hot water.
Choice C reason: Preparing the client for allergen testing is not relevant in the context of psoriasis. Psoriasis is an autoimmune condition, not an allergic reaction, so allergen testing would not provide useful information for managing the condition. The focus should be on identifying and managing triggers that can exacerbate psoriasis, such as stress, infections, and certain medications.
Choice D reason: Reviewing stress reduction strategies with the client is the most appropriate action. Stress is a known trigger for psoriasis flare-ups, and helping the client develop effective stress management techniques can significantly improve their symptoms. Techniques such as mindfulness, relaxation exercises, and counseling can be beneficial in reducing stress and minimizing psoriasis symptoms. Educating the client on the importance of stress management and providing them with practical strategies can empower them to better manage their condition.
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