A nurse enters a client's room to administer medication and finds the client lying in bed disoriented with labored and fast respirations. Which of the following actions should the nurse take first?
Prepare the client for endotracheal suctioning.
Elevate the head of the bed.
Request a chest x-ray.
Obtain a sputum culture.
The Correct Answer is B
A. Prepare the client for endotracheal suctioning.
Endotracheal suctioning is a procedure used to clear secretions from the airway, which may be necessary in cases of respiratory distress. However, it is not the first action to take in this scenario. Before proceeding with suctioning, the nurse should first assess the client's respiratory status and implement interventions to improve ventilation and oxygenation.
B. Elevate the head of the bed.
This is the correct action to take first. Elevating the head of the bed helps improve the client's respiratory mechanics by allowing better lung expansion and reducing the work of breathing. It also helps alleviate symptoms of respiratory distress. This intervention should be implemented immediately to optimize the client's breathing.
C. Request a chest x-ray.
While a chest x-ray may provide valuable information about the client's respiratory status, it is not the first action to take in this acute situation. Chest x-rays require time to be performed and interpreted, which may delay necessary interventions to address the client's immediate respiratory distress.
D. Obtain a sputum culture.
Obtaining a sputum culture may be indicated to identify the underlying cause of respiratory distress, such as infection. However, it is not the first action to take when the client is experiencing acute respiratory distress. The priority is to implement interventions to improve ventilation and oxygenation to stabilize the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the provider.
This choice suggests involving the healthcare provider immediately. While notifying the provider might eventually be necessary if the issue persists, it's not the initial action in this scenario. The nurse should first assess and troubleshoot the situation before escalating it to the provider.
B. Verify that the suction regulator is on.
This is the correct choice. When there is no bubbling in the suction control chamber of a chest tube, it may indicate that suction is not being applied properly. Verifying that the suction regulator is turned on and set to the correct level ensures that suction is being delivered to the chest tube.
C. Continue to monitor the client because this is an expected finding.
This choice is incorrect. The absence of bubbling in the suction control chamber is not an expected finding and suggests a potential problem with the suction system. Ignoring this finding without taking any action could lead to complications for the client.
D. Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Milking the chest tube is a technique used to maintain patency and promote drainage in chest tubes, but it should not be the first action when there is no bubbling in the suction control chamber. This action does not address the underlying issue of inadequate suction and may not be appropriate without first ensuring that suction is functioning correctly.
Correct Answer is A
Explanation
A. "You should inhale through your nose and exhale through your mouth during purse-lipped breathing."
Pursed-lip breathing is a breathing technique commonly used by individuals with COPD to help improve breathing efficiency and manage dyspnea (shortness of breath). During purse-lip breathing, the individual inhales slowly through the nose and exhales slowly and gently through pursed lips, creating a slight resistance to the airflow. This technique helps to keep the airways open longer during exhalation, reduces air trapping, and improves oxygenation.
B. "Your inspiration should be longer than expiration during purse-lipped breathing."
Pursed-lip breathing typically involves making both the inspiration and expiration longer than usual. The focus is on slowing down the breathing rate and extending the exhalation phase to promote better gas exchange and reduce respiratory effort.
C. "You should cough forcefully during exhalation when you are purse-lipped breathing."
Pursed-lip breathing is a gentle breathing technique used to promote relaxation and control of breathing. Forceful coughing during exhalation is not part of purse-lip breathing and may not be appropriate, especially for individuals with COPD who are prone to airway irritation and bronchospasm.
D. "You should be flat on your back when you perform purse-lipped breathing."
The position for performing purse-lip breathing is not specific to lying flat on the back. Individuals can perform purse-lip breathing in various positions that are comfortable and allow for effective breathing, such as sitting upright or leaning slightly forward. The key is to find a position that facilitates relaxation and optimal lung expansion.
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