To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?

Massage the client's bony areas every hour

Encourage the client to deep breathe and cough every hour

Provide tube feedings every two hours

Change the client's position every two hours

Answer and Explanation

The Correct Answer is B

B. Deep breathing and coughing exercises help to maintain lung expansion and prevent atelectasis (collapse of lung tissue), clear secretions from the airways, which can reduce the risk of respiratory infections like pneumonia, improve oxygenation and ventilation-perfusion matching in the lungs. Additionally, deep breathing exercises can stimulate circulation indirectly by improving oxygenation and gas exchange, which can benefit circulatory function.

A. Massaging bony areas can help prevent pressure ulcers (bedsores) in immobile patients, but it does not directly improve respiratory or circulatory functions. While skin integrity is important, it does not address the physiological needs of respiratory and circulatory systems.

C. While nutrition is important for overall health, especially in a nonresponsive client who may not be able to feed themselves orally, tube feedings primarily address nutritional needs and do not directly impact respiratory or circulatory functions. They are important for preventing malnutrition and supporting recovery, but they do not specifically target the goals of improving respiratory or circulatory functions.

D. Changing positions regularly is crucial for preventing complications such as pressure ulcers and maintaining skin integrity. It can also aid in improving circulation by relieving pressure on vulnerable areas and promoting blood flow. Proper positioning can optimize respiratory function by preventing pooling of secretions and improving lung ventilation. Additionally, positional changes encourage movement of the diaphragm and chest wall, which aids in ventilation and gas exchange.

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Correct Answer is B

Explanation

B. This response acknowledges the urgency of the situation and seeks clarification on the appropriate administration technique. It demonstrates readiness to follow through with the medical resident's directive while ensuring safe and effective administration.

A. This response reflects hesitation and a concern about administering a medication that the nurse did not prepare or is unfamiliar with. In a critical situation like a "code blue," timely administration of medications as directed by the medical team is crucial for patient outcomes.

C. Checking IV patency is important to ensure the medication can be administered properly. However, in a "code blue" situation where time is critical, this step might unnecessarily delay administration of the medication.

D. This response indicates willingness to follow the directive given by the medical resident. It also emphasizes the importance of documenting and obtaining proper orders after the immediate crisis has been addressed.

A. Ineffective Sexuality Pattern B. Risk for Social Isolation C. Activity Intolerance D. Imbalanced Nutrition: less than body requirements

Correct Answer is D

Explanation

D. This problem indicates that the client is not receiving adequate nutrition to meet metabolic needs, which can lead to malnutrition and compromised healing. Addressing imbalanced nutrition is crucial for maintaining health and supporting recovery.

A. This problem refers to disturbances in sexual function or satisfaction. While important to address, it is not typically considered a high priority compared to other physiological or safety-related issues unless it B This problem indicates the potential for the client to experience loneliness or social disconnection, which can impact mental and emotional well-being. While addressing social isolation is important for holistic care, it may not be as urgent as issues related to physical health or safety.

C This problem indicates the inability to endure physical activities or exercise due to insufficient physiological or psychological energy. Activity intolerance can be a significant concern post-operatively or in clients with chronic conditions, as it can affect recovery and overall functional ability.

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To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A non-critical care nurse is part of the team in a "code blue resuscitation effort. The medical resident hands the nurse an unlabeled syringe and says. Give this to the client IV push STAT Whet response by the nurse appropriate in this emergency situation

Correct Answer is B

Explanation

The nurse is prioritizing a client's problem list. Which of the following problems should receive the highest priority?

Correct Answer is D

Explanation

A client is to receive 2 liters of IV fluid at 125 ml/hr. How long should the nurse expect the IV fluids to last? Document number of hours.

The nurse prepares to assess the client's radial pulse. Which statement made by the nurse reflects a correct understanding of the procedure? "I will:

The phase of the nurse-client relationship that begins when the individuals first meet, and that is characterized by an agreement to continue meeting and assessing needs is the:

The nurse recognizes that the client's energy has been depleted despite attempts to intervene and the client dies. This is a description of which phase of the General Adaptation Syndrome?

A client is receiving IV fluids at 100 ml per hour. The nurse is told in report at 1200 that there are 500 ml left in the bag. At what time should the nurse expect to hang a new bag? Report the time in military time.

Which nursing activity is an example of using primary prevention in client care?

Which of the following are essential in the care for a patient with incontinence-associated dermatitis? (SELECT ALL THAT APPLY)