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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Increased urinary output. Furosemide is a loop diuretic that promotes diuresis by inhibiting sodium and water reabsorption in the kidneys. Increased urinary output indicates the medication is effectively reducing fluid volume, which is beneficial for clients with heart failure to decrease edema and pulmonary congestion.
B. Decreased BUN level. Blood urea nitrogen (BUN) levels can fluctuate due to hydration status and kidney function, but a decrease in BUN is not a primary indicator of furosemide’s effectiveness. Instead, BUN levels should be monitored for potential elevation, which could indicate dehydration or renal impairment as an adverse effect of the medication.
C. Decreased hemoglobin level. Furosemide does not directly affect hemoglobin levels. A decrease in hemoglobin may indicate anemia, which is not a desired or expected effect of diuretic therapy for heart failure.
D. Increased weight of 0.91 kg (2 lb). An increase in weight suggests fluid retention, which would indicate that heart failure is worsening rather than improving. Effective furosemide therapy should lead to weight reduction due to fluid loss, not weight gain.

A. "You can apply counterpressure to your back with each position change." B. "You should change positions as little as possible." C. "You should use patterned-paced breathing when changing positions." D. "You can splint the incision with a pillow when changing positions."

Correct Answer is D

Explanation

A. "You can apply counterpressure to your back with each position change." Counterpressure is commonly used for pain relief during labor, particularly for back labor caused by fetal positioning. It is not a typical nonpharmacological intervention for post-cesarean pain management.
B. "You should change positions as little as possible." Frequent position changes help promote circulation, prevent complications such as deep vein thrombosis, and reduce stiffness. Encouraging mobility with proper pain management is essential for recovery after a cesarean birth.
C. "You should use patterned-paced breathing when changing positions." Patterned-paced breathing is a technique used during labor for pain management and relaxation. While controlled breathing may help with general discomfort, it is not the most effective strategy for post-cesarean pain during movement.
D. "You can splint the incision with a pillow when changing positions." Holding a pillow against the incision site provides support, reduces strain on the abdominal muscles, and minimizes pain when moving, coughing, or laughing. This is a well-established method for post-cesarean pain relief.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

Correct Answer is A

Explanation

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

Exhibits Complete the following sentence by using the list of options The nurse should first address the client’s dropdownfollowed by the client’sdropdown

A nurse is reinforcing preoperative teaching with a client who is scheduled for a total laryngectomy. Which of the following information is the priority for the nurse to reinforce?

A nurse is reinforcing teaching about laboratory testing with a client. Which of the following findings should the nurse include as an indicator of infection?

A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?