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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Reinserting the PIV catheter restores IV access but is not the immediate priority. Ensuring restraints can be quickly released addresses safety, as delayed removal risks injury during emergencies. Restraint safety, mandated by regulatory standards, takes precedence to protect the client before addressing therapeutic devices like IVs.

Choice B reason: Verifying that restraints can be quickly released ensures client safety, as per Joint Commission standards. Rapid release is critical in emergencies, like choking or fire, to prevent harm. This action prioritizes client protection, ensuring restraints do not impede evacuation or intervention, making it the most immediate post-application step.

Choice C reason: Assessing capillary refill monitors circulation distal to restraints, which is important but secondary to ensuring quick release. Rapid release prevents harm in emergencies, a higher safety priority. Circulation checks are part of ongoing monitoring, but immediate restraint safety takes precedence to comply with regulatory and ethical standards.

Choice D reason: Replacing the NGT restores its function but is not the first priority after applying restraints. Ensuring quick release prevents entrapment or injury in emergencies, a critical safety concern. NGT replacement can follow once restraint safety is confirmed, as client protection from restraint-related risks is paramount.

A. Determine which member of the nursing staff brought the cup of coffee to the client. B. Remind the client that no milk or creamer can be added to the coffee. C. Consult with the dietician to learn if the client is allowed to drink coffee. D. Remove the coffee from the tray, advising the client that it is not included in the diet.

Correct Answer is B

Explanation

Choice A reason: Determining who brought the coffee is irrelevant to addressing the client’s dietary needs. A clear liquid diet includes black coffee, as it is transparent and easily digested. The priority is ensuring dietary compliance, not investigating staff actions, which does not impact the client’s immediate care or safety.

Choice B reason: Reminding the client that no milk or creamer can be added ensures adherence to a clear liquid diet, which includes black coffee. Coffee without additives is transparent and digestible, fitting dietary guidelines. This action educates the client, prevents dietary violations, and maintains the therapeutic purpose of the prescribed diet.

Choice C reason: Consulting the dietician is unnecessary, as black coffee is standard in clear liquid diets per nutritional guidelines. This action delays care and overcomplicates a straightforward issue. The nurse can directly clarify that coffee is allowed without additives, ensuring compliance without external consultation.

Choice D reason: Removing the coffee is incorrect, as black coffee is permitted in a clear liquid diet. This action unnecessarily restricts the client’s intake and may cause confusion or dissatisfaction. The nurse should instead educate the client about proper consumption, ensuring dietary adherence while maintaining patient comfort.

View Question and Answer

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

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

A prescription for bilateral soft wrist restraints is obtained for an older adult client who has repeatedly removed the nasogastric tube (NGT) and IV sites. After applying the restraints, which action is most important for the nurse to take?

Correct Answer is B

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse is providing education to an older adult client about activity and exercise. Which statement made by the client indicates a need for further teaching?

When identifying the goals to be included in a client’s plan of care, the nurse should take which action?

After a client voids, 150 ml of residual urine is noted. Which nursing problem should be included in the client’s plan of care?

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?

Which is the best method for the nurse to use to prepare the skin prior to administration of a topical ointment?

It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

The nurse is caring for a client who wears bilateral hearing aids. Which action should the nurse take when communicating with the client?