A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Administer oxygen to the client.

Notify the charge nurse.

Document client findings and interventions taken.

Place the client in high Fowler's position.

Answer and Explanation

The Correct Answer is D,A,B,C

D. Place the client in high Fowler’s position. Positioning the client upright maximizes lung expansion and improves oxygenation. This is the first step to alleviate respiratory distress before additional interventions.

A. Administer oxygen to the client. Once the client is positioned appropriately, providing supplemental oxygen helps increase oxygen saturation and relieve hypoxia. The nurse should titrate oxygen as needed according to facility protocols or provider orders.

B. Notify the charge nurse. After immediate interventions are in place, the nurse should inform the charge nurse to ensure further assessment and necessary medical interventions. The charge nurse may escalate care or contact the provider for additional management.

C. Document client findings and interventions taken. Once the client’s condition has been addressed and reported, documentation is necessary to record assessment findings, interventions provided, and the client's response. Accurate documentation ensures continuity of care and legal protection.

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Correct Answer is A

Explanation

A. The client's extremity should be elevated after the cast is applied. Elevating the extremity above heart level for the first 24 to 48 hours reduces swelling and prevents complications such as compartment syndrome. Ice packs can also be applied to minimize edema.
B. The client should keep the cast covered until it is dry. Covering a wet plaster cast can trap moisture and delay drying, increasing the risk of weakening the cast and skin irritation. Plaster casts should be left uncovered to allow proper air drying.
C. The client can shower with the cast after 24 hr. Plaster casts are not waterproof and should be kept dry at all times. If exposed to water, they can lose their shape and strength, potentially leading to improper healing. A plastic covering should be used when bathing.
D. The client should use a hair dryer on a warm setting to relieve itching inside the cast. Direct heat can weaken the plaster and cause burns. Instead, clients should use a cool hair dryer setting or tap lightly on the cast to manage itching without compromising its integrity.

A. Document the infiltration. B. Stop the infusion. C. Elevate the arm. D. Apply a warm compress.

Correct Answer is B

Explanation

A. "Document the infiltration." While documentation is necessary, it is not the first action the nurse should take. Immediate intervention is required to prevent further complications from IV infiltration, such as tissue damage or fluid leakage into surrounding tissues.
B. "Stop the infusion." The first action the nurse should take is to stop the IV infusion to prevent further infiltration of fluid into the surrounding tissues. Continuing the infusion could worsen swelling, discomfort, and potential tissue injury.
C. "Elevate the arm." Elevating the affected extremity can help reduce swelling by promoting fluid reabsorption, but this should be done after stopping the infusion to prevent additional fluid from accumulating in the tissues.
D. "Apply a warm compress." A warm compress can help promote absorption of non-vesicant solutions, while a cold compress is preferred for certain medications to reduce swelling and pain. However, applying a compress should only be done after stopping the infusion and assessing the severity of infiltration.

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A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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