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 B

Explanation

A. Medical health insurance claims. While insurance coverage is important for referral approval, the physical therapist primarily requires clinical information related to the client's mobility and functional status. Insurance details are handled by administrative staff rather than included in the clinical referral.
B. Physical assessment findings. The physical therapist needs relevant assessment findings, such as muscle strength, range of motion, balance, gait, and mobility limitations. These details help guide therapy goals and interventions to improve the client’s functional abilities.
C. Family medical history. While family history is useful for identifying genetic predispositions to conditions, it is not essential for a physical therapy referral. The focus should be on the client’s current physical status rather than hereditary factors.
D. Medications taken prior to admission. Although a client’s medication history is important for overall care, it is not the primary concern for a physical therapy referral unless specific medications affect mobility, such as muscle relaxants or sedatives. The therapist will rely more on current physical assessment findings to determine appropriate interventions.

A. Rigid abdomen B. Increased fetal movement C. Persistent uterine contractions D. Bright red vaginal bleeding

Correct Answer is D

Explanation

A. Rigid abdomen. A rigid or board-like abdomen is characteristic of placental abruption, not placenta previa. Placental abruption involves premature separation of the placenta from the uterine wall, leading to significant abdominal pain and uterine tenderness. In contrast, placenta previa typically presents with painless bleeding.
B. Increased fetal movement. Fetal movement is not directly affected by placenta previa unless there is severe hemorrhage leading to fetal distress. While decreased movement in cases of significant bleeding may indicate fetal compromise, increased movement is not a typical finding.
C. Persistent uterine contractions. Placenta previa does not usually cause persistent contractions. While mild uterine irritability may occur, placenta previa is primarily characterized by painless bleeding. Persistent contractions are more commonly associated with preterm labor or placental abruption.
D. Bright red vaginal bleeding. The hallmark sign of placenta previa is painless, bright red vaginal bleeding in the second or third trimester. This occurs due to the placenta covering or being near the cervical os, leading to bleeding as the cervix begins to dilate or efface.

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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 in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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