While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

Explain to the client the possible causes of dyspnea or "shortness of breath."

Ask the client to describe the episodes of dyspnea in more detail.

Document "dyspnea on exertion" in the client's medical record.

Ask the client to perform light exercise and observe the respiratory effort.

Answer and Explanation

The Correct Answer is B

A. Explain to the client the possible causes of dyspnea or "shortness of breath.": While the nurse might eventually explain this, it's premature without more information about the client's specific shortness of breath experience.

B. Ask the client to describe the episodes of dyspnea in more detail: This is the most appropriate next step. Understanding the characteristics, triggers, and severity of the dyspnea will help determine the cause and guide further assessment.

C. Document "dyspnea on exertion" in the client's medical record: The client only reports experiencing shortness of breath "at times," not necessarily with exertion. More details are needed before documenting.

D. Ask the client to perform light exercise and observe the respiratory effort: This could worsen the client's condition if the shortness of breath is severe. Observation during rest provides a safer approach initially.

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Correct Answer is C

Explanation

A: Apply a pulse oximeter to the foot. Continuous monitoring of oxygen saturation can help detect hypoxemia early, which can be a concern in post-term infants due to potential respiratory distress or meconium aspiration. However, while important, this is a monitoring measure and not an immediate corrective action for potential metabolic or respiratory issues directly associated with post-term birth.

B: Draw arterial blood gases. Arterial blood gases (ABGs) provide critical information about the newborn's acid-base balance, oxygenation, and ventilation status. Post-term infants are at risk for hypoxia and acidosis, often due to placental insufficiency or meconium aspiration. However, obtaining ABGs can be invasive and might not be the first-line immediate action unless there are signs of severe distress.

C: Obtain a capillary blood glucose. Post-term infants are at increased risk for hypoglycaemia due to increased glucose utilization and possible depletion of glycogen stores. Hypoglycaemia can lead to serious complications if not promptly identified and managed. Therefore, checking blood glucose levels is a critical, non-invasive, and immediate step to ensure metabolic stability and prevent complications such as seizures and brain injury.

D: Provide blow-by oxygen. Blow-by oxygen is used to provide supplemental oxygen in a non-invasive manner and can help in cases of mild respiratory distress. Post-term infants can be at risk for respiratory issues, including meconium aspiration syndrome. However, this is usually applied when there is evidence of respiratory distress and not as a routine measure without specific indications.

A. Takes a first step alone. B. Sits alone unsupported. C. Can feed self finger food. D. Pulls self to sitting position.

Correct Answer is D

Explanation

A. Takes a first step alone: This is typically achieved closer to 12 months.

B. Sits alone unsupported: Some 8-month-olds might achieve this, but pulling to sit is a more consistent milestone at this age.

C. Can feed self finger food: While some babies might explore finger foods at 8 months, independent feeding is usually a skill developed later.

D. Pulls self to sitting position: This demonstrates developing upper body strength and coordination, commonly seen around 8-9 months.

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While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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