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 D

Explanation

A. Use a moisturizing soap to clean the skin around the client's stoma. Using moisturizing soap is not recommended because it can leave a residue that interferes with the adhesion of the skin barrier. A mild, non-moisturizing soap should be used to cleanse the area, followed by thorough rinsing and drying.
B. Change the client's ostomy appliance 1 hr after breakfast. Changing the ostomy appliance should ideally be done when the stoma is less active, which is usually before meals or several hours after meals. Changing it right after breakfast may lead to difficulty managing output if the stoma is still active.
C. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma. The skin barrier opening should be cut to fit the stoma snugly, typically 1/8 inch (0.3 cm) larger than the stoma size, not 0.5 inches. A larger opening can lead to skin irritation and leakage.
D. Empty the client's ostomy pouch before removing the skin barrier. This is an important step to minimize the risk of spills and make the process more manageable. Emptying the pouch ensures that the contents do not leak out during the change, helping maintain a clean and safe environment during the procedure.

A. Remove the tape by pulling from the center of the dressing. B. Clean the wound from the center to the outer edges. C. Moisten the dressing before removal. D. Wear sterile gloves to remove the dressing

Correct Answer is B

Explanation

A. Remove the tape by pulling from the center of the dressing. Tape should be removed by pulling toward the wound rather than from the center to avoid skin trauma and unnecessary disruption to the healing tissue. Pulling from the center can increase discomfort and damage surrounding skin.
B. Clean the wound from the center to the outer edges. Cleaning from the center outward prevents the introduction of microorganisms from the surrounding skin into the wound, reducing the risk of further infection. This technique follows the principle of working from the cleanest area to the least clean.
C. Moisten the dressing before removal. A wet-to-dry dressing is meant to adhere to necrotic tissue and debris, which is then removed when the dry dressing is taken off. Moistening it before removal defeats this purpose by softening the dressing, reducing its effectiveness in debriding the wound.
D. Wear sterile gloves to remove the dressing. Clean gloves are appropriate for removing a contaminated dressing. Sterile gloves are necessary for applying the new dressing to maintain an aseptic environment. Using sterile gloves for removal is unnecessary and does not improve infection control.

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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 another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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