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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Alternate activity and rest. Clients with heart failure should balance activity and rest to prevent overexertion and minimize cardiac workload. Frequent rest periods help conserve energy and reduce symptoms such as dyspnea and fatigue.
B. Reduce sodium intake to 2 g per day. Limiting sodium intake helps prevent fluid retention and reduces the risk of worsening heart failure. Excess sodium contributes to increased blood volume and exacerbates symptoms such as edema and shortness of breath.
C. Consume a low-fiber diet. A low-fiber diet is not necessary for heart failure management. Adequate fiber intake is beneficial for preventing constipation, which can increase strain during bowel movements and lead to hemodynamic stress. A high-fiber diet is generally encouraged.
D. Gradually increase activity each day. Clients should slowly increase their activity level based on tolerance to improve cardiovascular function. Overexertion should be avoided, but regular, controlled exercise helps maintain mobility and enhance overall heart health.
E. Eat small, frequent meals each day. Eating smaller meals reduces gastric distension and minimizes pressure on the diaphragm, which can help alleviate shortness of breath. Large meals can increase metabolic demands and contribute to discomfort in clients with heart failure.
Correct Answer is A
Explanation
A. "You might experience swollen gums while taking this medication." Phenytoin is known to cause gingival hyperplasia, which is swelling and overgrowth of the gums. This is a common side effect, and clients should be informed about it so they can maintain good oral hygiene and seek dental care if necessary.
B. "You can skip a dose of this medication if you are nauseated." Skipping doses is not advised. Phenytoin should be taken consistently, and skipping doses can lead to decreased seizure control. If nausea occurs, the client should contact their healthcare provider for guidance.
C. "You can safely take this medication if you become pregnant." Phenytoin is classified as a Category D medication, indicating evidence of risk to the fetus. Women of childbearing age should discuss effective contraception and consult their healthcare provider regarding the risks associated with taking phenytoin during pregnancy.
D. "You should expect to have blood work every 6 months while taking this medication." Regular monitoring of serum levels is necessary, typically every 1-3 months, especially after dosage changes. Monitoring ensures therapeutic levels and prevents toxicity, so stating that blood work is only required every 6 months may be insufficient.
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