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: While heart rate is important, it is not the most immediate concern when a client shows signs of cyanosis.

Choice B reason: Blood pressure is a critical vital sign but does not directly address the issue of oxygenation, which is suggested by cyanosis.

Choice C reason: Temperature is less relevant to the immediate assessment of cyanosis, which is often related to oxygenation issues.

Choice D reason: Respiratory rate should be assessed first as cyanosis is a sign of potential hypoxia, and the respiratory rate can provide immediate information about the client's breathing and oxygenation status.

A. "Is there any particular reason why you think this is your fault?" B. "With surgery, your baby should have a full recovery." C. "This must be a very difficult time for you." D. "You did nothing wrong."

Correct Answer is C

Explanation

The correct answer is choice C. “This must be a very difficult time for you.”

Choice A rationale:

Asking the mother why she thinks it is her fault can make her feel defensive and does not provide the emotional support she needs at this moment. It may also imply that there could be a reason for her to feel guilty, which is not helpful.

Choice B rationale:

While it is important to provide hope and information about the prognosis, this response does not address the mother’s immediate emotional distress and feelings of guilt. It focuses on the future rather than acknowledging her current emotional state.

Choice C rationale:

This response is empathetic and acknowledges the mother’s feelings. It provides emotional support and validates her experience, which is crucial in helping her cope with the situation.

Choice D rationale:

Telling the mother she did nothing wrong is important, but it does not fully address her emotional distress. It is a factual statement that may not provide the comfort and understanding she needs at this moment.

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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

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

Correct Answer is D

Explanation

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

Correct Answer is C

Explanation

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