While assessing a patient, the nurse identifies a respiratory rate of 28 breaths per minute. Which action should the nurse prioritize?

Assess for signs of hypoxia and respiratory distress.

Administer supplemental oxygen immediately.

Document the finding and notify the provider.

Encourage the patient to breathe deeply and slowly.

Answer and Explanation

The Correct Answer is A

A. Assess for signs of hypoxia and respiratory distress: A respiratory rate of 28 breaths/min indicates tachypnea and may signal compromised oxygenation or increased work of breathing. Immediate focused assessment (oxygen saturation, use of accessory muscles, mental status) helps determine severity and guides next interventions.

B. Administer supplemental oxygen immediately: Oxygen may be needed, but it should follow a rapid assessment unless the patient is clearly unstable. Administering oxygen without assessment may mask the underlying cause of tachypnea.

C. Document the finding and notify the provider: Documentation and notification are important, but they are secondary to assessing the patient’s current respiratory status and identifying urgent signs of deterioration.

D. Encourage the patient to breathe deeply and slowly: This may be appropriate for anxiety-related tachypnea, but the cause of the increased respiratory rate must be assessed first to rule out hypoxia or acute respiratory compromise.

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Correct Answer is C

Explanation

A. Focus solely on providing physical symptom management for the client: Addressing physical symptoms is important, but anticipatory grief involves emotional and psychological processes. Limiting care to physical management neglects the client’s emotional needs.

B. Advise the client to avoid thinking about the loss to prevent emotional distress: Encouraging avoidance can suppress emotions, increase anxiety, and impede healthy grieving. Anticipatory grief is best addressed through acknowledgment and expression of feelings.

C. Encourage the client to discuss their feelings openly with loved ones: Facilitating open communication helps the client process emotions, strengthens social support, and promotes coping during the terminal illness. Sharing feelings aligns with therapeutic interventions for anticipatory grief.

D. Recommend the client to isolate themselves to cope privately with their grief: Isolation can exacerbate feelings of loneliness and depression. Supportive interaction with family, friends, or counselors is generally more beneficial for emotional well-being during anticipatory grief.

A. Always carry personal protective equipment in a visible manner. B. Always start the visit by discussing the client's medical history. C. Request the client to leave the room during the nurse's assessment. D. Ask for permission before entering each room in the home.

Correct Answer is D

Explanation

A. Always carry personal protective equipment in a visible manner: While PPE is important for infection control, displaying it prominently may create fear or imply mistrust. PPE should be used appropriately without compromising rapport or household comfort.

B. Always start the visit by discussing the client's medical history: Beginning with medical history may overlook establishing rapport and respecting the client’s household norms. Initial engagement should prioritize trust, cultural sensitivity, and comfort before detailed health discussions.

C. Request the client to leave the room during the nurse's assessment: Asking the client to leave is unnecessary and may be perceived as disrespectful or intrusive. Assessments should involve the client when appropriate, maintaining privacy and dignity without excluding them unnecessarily.

D. Ask for permission before entering each room in the home: Seeking permission demonstrates respect for the client’s privacy, personal space, and household values. It establishes trust, supports safety, and aligns with culturally sensitive, patient-centered care practices.

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While assessing a patient, the nurse identifies a respiratory rate of 28 breaths per minute. Which action should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention is most appropriate for a nurse to implement when a client is experiencing anticipatory grief due to a terminal illness diagnosis?

Correct Answer is C

Explanation

When visiting a client's home, which action should the nurse take to ensure personal safety and respect the client's household values?

Correct Answer is D

Explanation

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