A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?

Diaphragmatic breathing

Controlled breathing

Pursed-lip breathing

Use of accessory muscles

Answer and Explanation

The Correct Answer is D

A. Diaphragmatic breathing:

Diaphragmatic breathing, also known as abdominal or deep breathing, is a normal and effective way of breathing. It involves the contraction and relaxation of the diaphragm, allowing for efficient lung expansion. This is a healthy and efficient breathing technique.

B. Controlled breathing:

Controlled breathing refers to a deliberate and regulated breathing pattern. It can include techniques such as paced breathing, where the individual consciously controls the rate and depth of their breaths. Controlled breathing is generally considered a positive and intentional approach to managing respiratory function.

C. Pursed-lip breathing:

Pursed-lip breathing is a breathing technique where the individual breathes in through the nose and exhales through pursed lips. This method is often taught to individuals with certain respiratory conditions, such as chronic obstructive pulmonary disease (COPD), to help improve lung function and alleviate shortness of breath. Pursed-lip breathing can be a helpful strategy in specific situations.

D. Use of accessory muscles:

The use of accessory muscles indicates that the person is experiencing increased difficulty in breathing. Accessory muscles, such as the neck and shoulder muscles, are not typically heavily involved in breathing under normal circumstances. When these muscles are visibly working during breathing, it suggests increased respiratory effort and can be a sign of respiratory distress or difficulty.

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Correct Answer is D

Explanation

A. The client with a history of a myocardial infarction who has a p wave before every QRS complex.

This may indicate a heart block, which requires attention. However, it's not an immediate life-threatening situation.

B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.

Bilateral pitting pedal edema is a sign of fluid overload, which is concerning and requires attention.

C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue.

While bradycardia and fatigue are concerns, they might not be as urgent as the client with fluid overload.

D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.

New onset of severe indigestion in a client with coronary artery disease raises concern for a potential cardiac event, and this should be addressed promptly.

A. withhold food and oral fluids before the procedure B. review medications the client has taken in the last 24 hours C. verify that written consent has been obtained D. check for iodine sensitivity E. administer all ordered oral medications

Correct Answer is ["A","B","C","D"]

Explanation

Withhold food and oral fluids before the procedure

Withholding food and oral fluids before the procedure is essential to prevent complications during the cardiac catheterization. The client is typically NPO (nothing by mouth) for a specified period before the procedure.

B. Review medications the client has taken in the last 24 hours

Reviewing the client's medications is crucial to ensure that any medications affecting coagulation or blood vessels are appropriately managed before the cardiac catheterization.

C. Verify that written consent has been obtained

Verifying the presence of written consent is a critical step to confirm that the client has been adequately informed about the procedure, its risks, and benefits, and has given consent for the cardiac catheterization.

D. Check for iodine sensitivity

Checking for iodine sensitivity is important because iodinated contrast dye is commonly used during cardiac catheterization. Allergies or sensitivities to iodine contrast must be identified to prevent adverse reactions.

E. Administer all ordered oral medications

Administration of oral medications before the procedure depends on the specific medications and the healthcare provider's instructions. Some medications may be held, while others may be continued as prescribed.

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A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a team of assigned clients. Which client is a priority for the nurse to check on first?

Correct Answer is D

Explanation

A client is scheduled for a cardiac catheterization. The nurse should do which of the following pre-procedure tasks? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D"]

Explanation

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