A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?

Document the presence of orthopnea.

Elevate the head of the bed.

Obtain a pulse oximeter.

Assess the client's vital signs.

Answer and Explanation

The Correct Answer is B

A.   Orthopnea is a condition where a person has difficulty breathing when lying flat and may require sitting or standing to breathe more easily. While documenting orthopnea is important for the medical record and understanding the client’s condition, it is not the immediate priority in addressing acute breathing difficulty.
B.   Elevating the head of the bed is an immediate and effective action to help alleviate breathing difficulty. This position helps improve respiratory mechanics by allowing the diaphragm to move more freely and reducing pressure on the lungs.
C.   Using a pulse oximeter to measure oxygen saturation is important for assessing the client’s oxygen levels and determining the need for supplemental oxygen. However, this action is secondary to immediately addressing the position that is causing difficulty.
D.   Assessing vital signs is important for a comprehensive evaluation of the client’s overall condition and to identify any critical changes in health status. However, in the case of immediate breathing difficulty, it is more urgent to take actions that directly address the breathing issue before performing a thorough assessment.

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Correct Answer is A

Explanation

A. Positioning the package of gauze pads on a sterile field is an appropriate action to maintain sterility and ensure that all items used in the procedure remain uncontaminated. However, this step should be considered only if the solution was poured correctly and the sterility of the gauze pads and solution has been maintained.
B. Discarding the open bottle of solution is not necessary unless it has been contaminated. If the solution is still sterile and has not been contaminated (e.g., by touching non-sterile surfaces), there is no need to discard it. The focus should be on ensuring that the solution and all other items remain sterile.
C. Recapping the solution is not recommended because it can lead to contamination. Instead, the solution should be left open or covered with a sterile cap, if provided. Applying sterile gloves is essential for maintaining sterility during the dressing change procedure, but this should be done after ensuring that all supplies and steps are in order.
D. This action would be necessary only if there was a contamination issue or if the sterility of the supplies or solution was compromised. If the sterile technique was not followed properly or there was a risk of contamination, starting the procedure again with new supplies would be appropriate.

A. Provide a box of tissues for the client to use when coughing. B. Assist the client in changing into a fresh hospital gown. C. Teach the client to cover the mouth with hands when coughing. D. Obtain face masks for staff to wear upon entering the room.

Correct Answer is A

Explanation

A.Providing tissues is a helpful measure for clients to use when they need to cough or sneeze. It promotes good hygiene by allowing the client to dispose of respiratory secretions properly. However, this choice does not address the immediate concern of how the client is currently coughing and the potential for spreading infection.
B.Assisting the client with a gown change may be necessary if their current gown is soiled. However, this action does not directly address the infection control issue or the client’s method of coughing. Changing the gown is secondary to addressing proper coughing techniques and infection control.
C.Teaching clients to cover their mouth with their hands is not ideal, as it can spread germs if the hands are not washed immediately afterward. Instead, clients should be taught to cough into a tissue or their elbow (not the sleeve) to minimize the spread of germs. This is a crucial component of infection control and helps reduce the risk of transmission.
D.Providing face masks for staff is an important measure in infection control, especially if the client has a respiratory illness. However, it does not address the client's current coughing technique or teach the client how to prevent the spread of infection through their own actions.

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A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

Correct Answer is A

Explanation

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Correct Answer is A

Explanation

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