Which action should the nurse implement for a client with shortness of breath, dyspnea on exertion, and chest pressure?

Assist the client to a position that helps the client breathe more easily.

Document the client’s asymmetric thoracic movement during inspiration.

Provide the client an incentive spirometer to increase respiratory effort.

Encourage the client to continue to breathe deeply to expand the lungs.

Answer and Explanation

The Correct Answer is A

Choice A reason: Assisting the client to a position like high Fowler’s alleviates shortness of breath by optimizing lung expansion and reducing chest pressure. This immediate intervention improves oxygenation and comfort, critical for dyspnea. Positioning is evidence-based for respiratory distress, addressing the client’s acute symptoms before further assessment or interventions.

Choice B reason: Documenting asymmetric thoracic movement is an assessment, not an intervention, and delays relief of dyspnea. While useful for identifying underlying causes, it does not address immediate shortness of breath or chest pressure. Positioning the client for easier breathing is the priority to stabilize respiratory function and improve comfort.

Choice C reason: Providing an incentive spirometer encourages deep breathing but is less urgent than positioning for immediate dyspnea relief. Spirometry is preventive or rehabilitative, not suitable for acute shortness of breath. Positioning optimizes lung expansion instantly, addressing the client’s respiratory distress and chest pressure more effectively in this scenario.

Choice D reason: Encouraging deep breathing may exacerbate dyspnea or fatigue in acute respiratory distress. Positioning the client first reduces work of breathing, making subsequent deep breathing easier. Without optimizing position, deep breathing is less effective and may increase discomfort, making it a secondary intervention for this client’s symptoms.

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Hard pellets indicate constipation, potentially due to dehydration, low fiber, or medication side effects. This warrants follow-up to prevent impaction or discomfort. Constipation can lead to straining, hemorrhoids, or bowel obstruction, requiring interventions like hydration, dietary changes, or laxatives to restore normal bowel function and client comfort.

Choice B reason: Formed but soft stools are normal, reflecting healthy bowel function with adequate hydration and fiber. This description does not require follow-up, as it indicates no immediate pathology. Normal stools vary in consistency, but soft, formed stools align with optimal gastrointestinal health, requiring no further nursing intervention at this time.

Choice C reason: Solid stools with red streaks suggest fresh blood, possibly from hemorrhoids, fissures, or lower gastrointestinal bleeding. This requires urgent follow-up to identify the source and assess bleeding severity. Blood in stools can indicate serious conditions like colorectal pathology, necessitating diagnostic evaluation and intervention to prevent complications.

Choice D reason: Tarry stools indicate melena, suggesting upper gastrointestinal bleeding, possibly from ulcers or gastritis. This is a critical finding requiring immediate follow-up to assess hemoglobin, vital signs, and bleeding source. Melena can lead to anemia or shock if untreated, making prompt nursing assessment and intervention essential for client safety.

Choice E reason: Brown liquid stools suggest diarrhea, potentially from infection, medication, or dietary issues. This warrants follow-up to assess dehydration, electrolyte imbalance, or infectious causes like C. difficile. Diarrhea risks skin breakdown and fluid loss, requiring nursing interventions like fluid replacement and stool testing to address underlying causes.

A. Monitor heart rate to keep within the suggested range. B. Avoid exercises that impact chronic conditions. C. Focus on exercises that help with balance. D. Complete 30 minutes of exercise at least 3 times a week.

Correct Answer is B

Explanation

Choice A reason: Monitoring heart rate to stay within a suggested range is correct, ensuring safe exercise intensity for older adults. This prevents overexertion, especially with cardiovascular conditions. The statement reflects understanding, as it aligns with evidence-based guidelines for safe exercise, requiring no further teaching on this point.

Choice B reason: Avoiding exercises that impact chronic conditions is overly restrictive and incorrect. Many chronic conditions, like arthritis or diabetes, benefit from tailored exercise to improve function and health. This statement suggests misunderstanding, requiring teaching to clarify that appropriate exercises can manage, not exacerbate, chronic conditions, per geriatric care guidelines.

Choice C reason: Focusing on balance exercises is appropriate for older adults to prevent falls, a major injury risk. This statement shows understanding, as balance training improves stability and safety. No further teaching is needed, as it aligns with evidence-based recommendations for exercise in aging populations to enhance mobility.

Choice D reason: Completing 30 minutes of exercise at least 3 times a week aligns with CDC guidelines for older adults, promoting cardiovascular health and strength. This statement reflects correct understanding of exercise frequency and duration, requiring no further teaching, as it supports safe, effective physical activity for health maintenance.

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Which action should the nurse implement for a client with shortness of breath, dyspnea on exertion, and chest pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D"]

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Correct Answer is B

Explanation

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