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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "I will wipe away yellow crusts that form around the incision." Yellow crusting at the incision site is a normal part of the healing process. It should not be wiped away, as doing so could disrupt healing and cause irritation or bleeding. Instead, the area should be kept clean and allowed to heal naturally.
B. "I will apply antibiotic ointment to my baby's penis." The Plastibell technique does not require the application of antibiotic ointment. Unlike other circumcision methods, the Plastibell ring remains in place and falls off on its own within 5 to 8 days, reducing the need for additional topical treatments.
C. "I will make sure that my baby's diaper is applied snugly." The diaper should be applied loosely to prevent excessive pressure or friction on the healing area. A snug diaper can cause discomfort and increase irritation, potentially delaying healing.
D. "I will apply pressure with gauze if I see bleeding." Minor bleeding may occur after circumcision, and applying gentle pressure with sterile gauze is the appropriate action to control it. If bleeding persists beyond a few minutes or is excessive, medical attention should be sought immediately.

A. Sarcoptes scabiei B. Impetigo contagiosa C. Neisseria gonorrhoeae D. Human papillomavirus

Correct Answer is C

Explanation

A. "Sarcoptes scabiei." Sarcoptes scabiei is the parasitic mite that causes scabies, a contagious skin condition. While scabies is highly transmissible through direct contact, it is not a nationally notifiable disease and does not require mandatory reporting to the state health department.
B. "Impetigo contagiosa." Impetigo is a bacterial skin infection commonly caused by Staphylococcus aureus or Streptococcus pyogenes. Although it is contagious, it is not classified as a reportable disease at the national level, though some local jurisdictions may require reporting in outbreak situations.
C. "Neisseria gonorrhoeae." Gonorrhea is a sexually transmitted infection caused by Neisseria gonorrhoeae and is a nationally notifiable disease. Healthcare providers are required to report cases to public health authorities for surveillance, tracking, and prevention efforts, as untreated gonorrhea can lead to serious complications such as pelvic inflammatory disease, infertility, and neonatal infections.
D. "Human papillomavirus." Human papillomavirus (HPV) is the most common sexually transmitted infection, with multiple strains that can cause genital warts and cervical cancer. Although HPV is a significant public health concern, individual cases are not typically required to be reported to state health departments unless part of a specific surveillance program.

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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 about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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