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 C

Explanation

A. Morphine is a potent opioid used for pain relief, but it can have side effects, including respiratory depression. While it is important to be aware of and discuss potential side effects, focusing on
respiratory problems might increase the client’s anxiety about using the medication.
B. A PCA pump allows patients to self-administer pain medication within prescribed limits, providing more control over pain management. However, PCA pumps are typically used in hospital settings and may not be practical or appropriate for home hospice care.
C. Providing a schedule for around-the-clock analgesic use is a practical and effective approach to pain management. It ensures that the client receives consistent pain relief and helps prevent the pain from becoming unmanageable.
D. Teaching the family to evaluate the effectiveness of analgesics is important for ongoing pain management. This includes recognizing signs of pain relief and potential side effects. However, this action might be more relevant once pain management is underway and requires follow-up, rather than addressing the immediate concern of managing pain effectively from the start.

A. Practices bicep and triceps isometric exercises. B. Progresses to foot touchdown and weight bearing of affected leg. C. Bears body weight on the palms of hands during the crutch gait. D. Inspects crutches to ensure rubber tips are intact.

Correct Answer is C

Explanation

A. While practicing strength-building exercises for the arms, such as isometric exercises for the biceps and triceps, is beneficial for overall crutch use, it does not directly indicate proper crutch walking technique.
B. This choice is not correct for a three-point gait, especially in the case of a broken foot. In a three-point gait, the client should avoid bearing weight on the affected leg, as this gait is used to promote healing of a non-weight-bearing limb.
C. This behavior indicates a correct understanding of crutch walking. In the three-point gait, the client should bear weight on the crutches' handles and not on the armpits, which helps prevent nerve damage and provides better stability.
D. While it is important for safety to ensure that the rubber tips of the crutches are intact and not worn out, this behavior does not directly demonstrate the client’s understanding of the three-point gait technique.

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

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In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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