A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

Offer fruit juice at least twice during both the day and evening shifts.

Encourage the client to eat all of the meals that are sent.

Lower the bed prior to helping the client to move up in bed.

Have the client hold a pillow over the abdomen to cough and deep breathe.

Answer and Explanation

The Correct Answer is D

Choice A reason: Offering fruit juice is part of good nutrition and hydration but does not directly assist with the client's breathing difficulty.

Choice B reason: Encouraging the client to eat all meals is important for nutritional support, but it is not the most critical action related to the client's immediate respiratory comfort.

Choice C reason: Lowering the bed may be a safety measure but does not address the client's need for respiratory support.

Choice D reason: Having the client hold a pillow over the abdomen can help splint the chest while coughing, reducing discomfort and facilitating deep breathing, which is essential for a client with emphysema experiencing difficulty breathing.

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Correct Answer is D

Explanation

Choice A reason: Recording the client's pulse rate and rhythm is part of the assessment, but it is not the first action to take when assessing for orthostatic hypotension.
Choice B reason: Assisting the client to stand is part of the assessment process, but it should be done after the initial blood pressure and pulse have been measured while the client is supine.
Choice C reason: Applying the blood pressure cuff securely is necessary for an accurate reading, but it is not the first step in the process of assessing for orthostatic hypotension.
Choice D reason: The first action is to position the client supine for a few minutes before taking the initial blood pressure and pulse measurements, as this provides a baseline for comparison when the client stands.

A. Dizziness can occur during cleansing. B. The pubic area should be kept shaved. C. The foreskin should not be retracted. D. An erection may occur while providing care.

Correct Answer is D

Explanation

Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.

Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.

Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.

Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.

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A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

Correct Answer is D

Explanation

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Correct Answer is D

Explanation

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