Upon going in to assess, the LPN notices the client is having difficulty breathing. The client is currently in semi-Fowler’s position. The priority action is which of the following?
Reassure the client while placing them into the Trendelenburg position
With the help of the UAP (unlicensed assistive personnel), place the client into Sims position
Using the bedside table, assist the client to the orthopneic position
Place the client flat in supine position to rest
The Correct Answer is C
Choice A reason: Trendelenburg position (head down, feet elevated) is contraindicated in patients with breathing difficulty because it increases pressure on the diaphragm and worsens respiratory distress.
Choice B reason: Sims position is a side-lying posture used for rectal exams or procedures, not for relieving dyspnea. It does not optimize lung expansion or ease breathing.
Choice C reason: Orthopneic position (sitting upright, leaning forward with arms supported on a bedside table) is the priority intervention for difficulty breathing. This position maximizes lung expansion, reduces pressure on the diaphragm, and facilitates accessory muscle use, improving oxygenation.
Choice D reason: Supine position worsens breathing difficulty by limiting chest expansion and increasing pressure on the diaphragm. It is inappropriate for a patient in respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because the wheelchair must be locked before transfer to prevent movement and ensure patient safety. An unlocked wheelchair increases the risk of falls and injury.
Choice B reason: This is incorrect because a wide base of support, not a narrow one, is essential for stability during transfers. A narrow base increases the risk of losing balance.
Choice C reason: This is the correct action because positioning the bed so the patient’s feet are flat on the floor ensures stability and proper body mechanics during transfer. It reduces the risk of falls and helps the patient maintain balance.
Choice D reason: This is incorrect because limiting the patient’s movement is not appropriate. Patients should be encouraged to participate in transfers to the extent possible, which promotes independence and safety.
Correct Answer is D
Explanation
Choice A reason: Checking for a carotid pulse for one full minute is inappropriate in an emergency because it delays initiation of CPR. Pulse checks should be brief to avoid wasting critical time.
Choice B reason: Checking an apical pulse for 30 seconds is not appropriate in an unresponsive patient. Apical pulse assessment is used for routine monitoring, not emergency situations.
Choice C reason: Counting the radial pulse for one full minute is inappropriate because radial pulses may be absent in cardiac arrest, and this delays life-saving interventions.
Choice D reason: This is the correct action because in an unresponsive patient, the nurse should check for a carotid pulse for no longer than 10 seconds. If no pulse is detected, CPR should be initiated immediately. This aligns with current resuscitation guidelines, which emphasize minimizing delays in chest compressions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.