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. Can be a result of an early bowel obstruction. Hyperactive bowel sounds are characterized by loud, high-pitched, and frequent gurgling or rushing noises. They occur when there is increased intestinal motility, which can be seen in conditions such as gastroenteritis, diarrhea, or the early stages of a mechanical bowel obstruction. As the obstruction progresses, bowel sounds may become hypoactive or absent.
B. No sounds heard after listening for 3 to 5 min. This finding indicates absent bowel sounds, not hyperactive ones. Absent bowel sounds suggest complete bowel obstruction, paralytic ileus, or peritonitis and require immediate medical evaluation.
C. Sounds are soft and at a rate of 1/min. Hypoactive bowel sounds, rather than hyperactive ones, are characterized by infrequent, soft, or sluggish sounds occurring at a rate of less than 5 sounds per minute. Hypoactive bowel sounds are often associated with postoperative recovery, peritonitis, or late-stage bowel obstruction.
D. Indicates decreased motility. Hyperactive bowel sounds indicate increased, not decreased, intestinal motility. Decreased motility is associated with hypoactive or absent bowel sounds, which can occur due to conditions such as ileus, bowel obstruction, or the effects of certain medications, including opioids.

A. The client's extremity should be elevated after the cast is applied. B. The client should keep the cast covered until it is dry. C. The client can shower with the cast after 24 hr. D. The client should use a hair dryer on a warm setting for relieve itching inside the cast.

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.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

Correct Answer is A

Explanation

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

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