What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?

Reduce environmental stimuli

Suction the oropharynx

Assess pulse oximetry

Administer oxygen

Answer and Explanation

The Correct Answer is A

A. Restlessness and agitation in nonverbal clients can often be exacerbated by environmental factors such as noise, bright lights, or unfamiliar surroundings. By reducing environmental stimuli, such as dimming lights, minimizing noise, and providing a calm atmosphere, the nurse can help alleviate agitation and promote a more comfortable environment for the client.

B. Suctioning the oropharynx is not typically the first action unless there is a clear indication that airway obstruction or secretion management is contributing to the client's agitation. It is important to first assess whether there are signs of respiratory distress or airway compromise before performing suctioning.

C. Assessing pulse oximetry is important for monitoring oxygen saturation levels, especially if there are concerns about respiratory distress or inadequate oxygenation. However, it is not typically the first action when a client is restless and agitated unless there are specific indications or signs suggesting respiratory compromise.

D. Administering oxygen may be necessary if there are signs of hypoxia or respiratory distress contributing to the client's agitation. However, without assessing the client's oxygenation status first, administering oxygen as the initial action may not address the underlying cause of agitation.

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Correct Answer is B

Explanation

B. Heard over most of the lung fields, except for the major bronchi and the trachea.

Low intensity and pitch, with a longer inspiratory phase than expiratory phase. They are softer and more breezy in quality. Vesicular breath sounds are heard over the peripheral lung fields, including the apex (top) of the lungs.

A. Heard over the major bronchi, which are near the sternum and between the scapulae. They are of intermediate intensity and pitch, with equal inspiration and expiration phases. They are typically heard in the 1st and 2nd intercostal spaces along the sternal border and between the scapulae.

C. Heard over the trachea and larynx.

Characteristics: High intensity and pitch, with a short inspiratory phase and a longer expiratory phase. They are louder and harsher in quality, resembling the sound of air blowing through a hollow pipe.

D. Crackles are abnormal breath sounds that can be fine or coarse.

Fine crackles are high-pitched, short, popping sounds heard during inspiration, often due to fluid in the small airways or alveoli.

Coarse crackles are loud, low-pitched, bubbling sounds heard during inspiration, typically due to the presence of secretions in the larger airways.

A. external rotation B. extension C. adduction D. supination E. flexion

Correct Answer is ["A","B","C","E"]

Explanation

A. External rotation of the hip involves rotating the thigh outward away from the midline of the body. This movement occurs in the hip joint. External rotation is a component of hip range of motion.

B. Extension of the hip involves moving the thigh backward, straightening the leg from a flexed position. This movement also occurs in the hip joint. Extension is part of the hip's range of motion.

C. Adduction of the hip involves moving the thigh toward or across the midline of the body. It brings the leg closer to the midline. Adduction is another movement that is part of the hip's range of motion.

E. Flexion of the hip involves bringing the thigh toward the abdomen or bending the leg. It is a movement where the angle between the thigh and the abdomen decreases. Flexion is a fundamental movement of the hip joint.

D. Supination is a movement primarily associated with the forearm and hand, involving turning the palm upward or facing forward. It is not a movement of the hip joint. Supination is not correct in the context of hip range of motion.

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What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?

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Naxlex Comprehensive Predictor Exams

When auscultating over the apex of the client's lung field, what breath sound should the nurse expect to hear?

Correct Answer is B

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