Your patient is breathing shallowly and seems irritable and restless. A nursing action that might help is to have him:
take a good nap
turn, cough and deep breathe
submit to a back rub
take some pain medication
The Correct Answer is C
A. Take a good nap: While rest is important, shallow breathing and irritability may indicate inadequate ventilation, which won't improve solely with sleep.
B. Turn, cough, and deep breathe: This helps open the airways, promotes alveolar expansion, and clears secretions, which may improve oxygenation and reduce restlessness.
C. Submit to a back rub: Although comforting, it does not directly address shallow breathing or improve oxygenation.
D. Take some pain medication: Pain control can be essential, but this action is premature without assessing whether pain is the cause of shallow breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. More than 250 mL of air moves in and out of the lungs with each breath: This describes tidal volume but does not directly stimulate the cough mechanism.
B. Foreign substances are propelled by the cilia toward the respiratory tract: Irritation by foreign particles stimulates the cough reflex to clear the airways.
C. Dehumidified air enters the upper airway passages: Dry air can cause airway irritation but does not consistently trigger a cough reflex.
D. The blood transports carbon dioxide to the lungs: This describes gas exchange, which does not directly relate to triggering the cough mechanism.
Correct Answer is B
Explanation
A. Removing any adhesive from the patient's skin with acetone: Acetone is highly flammable and should not be used near oxygen equipment.
B. Assessing equipment in room for frayed cords: Frayed cords can cause electrical sparks, which may ignite in an oxygen-rich environment.
C. Reducing humidification on the oxygen delivery device: Humidification is essential to prevent mucosal dryness; reducing it unnecessarily can cause airway irritation.
D. Using clothing of synthetic cloth for the patient: Synthetic materials generate static electricity, which can ignite in the presence of oxygen. Cotton clothing is preferred.
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