When entering the room to administer scheduled daily medications, the nurse observes the client leaning forward and using pursed-lip breathing. Which action is most important for the nurse to take?
Auscultate the lungs for evidence of wheezing.
Quickly administer scheduled medications.
Ask the client if an anxiolytic is needed.
Evaluate the client's oxygen saturation.
The Correct Answer is D
A. Auscultate the lungs for evidence of wheezing: Lung auscultation is helpful in assessing respiratory status, but evaluating oxygen saturation is more urgent in this situation. It provides an immediate, objective measure of gas.
B. Quickly administer scheduled medications: Administering medications without assessing the client’s respiratory status may be unsafe. The client’s posture and breathing pattern suggest respiratory distress, which should be evaluated before giving medications.
C. Ask the client if an anxiolytic is needed: Anxiety may worsen breathing, but the client’s body language likely indicates a physiological rather than psychological problem. Assessing oxygenation is more important than addressing anxiety in this context.
D. Evaluate the client’s oxygen saturation: Pursed-lip breathing and forward-leaning posture are compensatory mechanisms seen in respiratory distress, often in clients with COPD. Assessing oxygen saturation immediately helps determine the severity of hypoxia and guides appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- Congestive cardiomyopathy is the most likely condition given the client’s symptoms of labored breathing, bilateral leg edema, S3 gallop, and apical pulse displacement—all signs of fluid overload and decreased cardiac output associated with heart failure.
- Applying oxygen helps manage dyspnea and improves tissue oxygenation in clients with heart failure, especially when respiratory rate is elevated and breathing is labored.
- Requesting a chest x-ray allows for visualization of pulmonary congestion or cardiomegaly, both of which are common in heart failure and can guide further treatment decisions.
- Monitoring breath sounds helps detect improvement or worsening of pulmonary congestion, such as crackles or rales, which indicate fluid buildup in the lungs.
- Monitoring urine output evaluates kidney perfusion and fluid status, which reflects the effectiveness of heart failure treatment and overall cardiac output.
- Hypertrophic cardiomyopathy typically presents with exertional syncope or chest pain, not fluid overload signs like leg edema and S3 gallop. Apical displacement also favors dilation rather than hypertrophy.
- Dilated cardiomyopathy overlaps with congestive cardiomyopathy, but the broader term “congestive” aligns more clearly with fluid overload and heart failure signs.
- Restrictive cardiomyopathy involves impaired ventricular filling but does not usually present with displaced apical pulse or bilateral edema in early stages. It is also less common in this clinical setting.
- Starting IV fluids would worsen the client’s condition by increasing preload and exacerbating fluid overload in heart failure.
- Giving the client 80 mg of aspirin is more appropriate in acute coronary syndrome, not in managing cardiomyopathy or fluid retention.
- Preparing for cardioversion is indicated in arrhythmias like atrial fibrillation with hemodynamic instability, not in a hemodynamically stable patient with heart failure.
- Monitoring platelet count is not relevant to evaluating heart failure progression or response to treatment.
- Monitoring temperature is important for infection but does not reflect cardiac or fluid status in this context.
- Monitoring cerebral perfusion pressure is reserved for neurocritical care settings and is not appropriate for routine heart failure monitoring.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"},"F":{"answers":"B"}}
Explanation
- Epigastric distress: Epigastric discomfort can occur in both angina and myocardial infarction due to referred pain or visceral irritation from ischemia. Clients may confuse this with indigestion, particularly in atypical presentations.
- Occurring without cause: Myocardial infarction pain often occurs suddenly and unpredictably, including during rest or sleep. It is not always precipitated by physical exertion or emotional stress, unlike classic stable angina.
- Pain only relieved by opioids: Myocardial infarction pain is severe and typically not responsive to nitroglycerin alone. Relief often requires opioid analgesics like morphine, which also help reduce cardiac workload.
- Feelings of fear: A sense of impending doom or intense anxiety is commonly reported in both angina and myocardial infarction, likely due to sympathetic nervous system activation during cardiac distress.
- Chest pain radiating down arm: Radiation of pain, especially to the left arm, is classic in both angina and myocardial infarction. It reflects the shared neural pathways between the heart and upper extremity.
- Pain relieved by nitroglycerin: Angina is typically responsive to rest and nitroglycerin, which dilates coronary arteries and reduces oxygen demand. In contrast, MI pain often persists despite nitroglycerin.
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