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. Administer IV morphine.
IV morphine may be indicated to relieve pain and anxiety associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.
B. Begin oxygen therapy.
The priority intervention for a client who develops a pulmonary embolism is to begin oxygen therapy. Pulmonary embolism (PE) is a life-threatening condition characterized by a blockage in one or more of the pulmonary arteries, usually due to a blood clot. This blockage can lead to impaired gas exchange and decreased oxygenation of the blood, resulting in hypoxemia (low blood oxygen levels) and potentially leading to respiratory failure. Administering oxygen therapy promptly helps to improve oxygenation and support vital organ function. Therefore, it is the priority intervention to address the immediate respiratory distress associated with a pulmonary embolism.
C. Start an IV infusion of lactated Ringer's.
Intravenous fluid administration may be necessary to maintain hemodynamic stability and support perfusion in a client with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.
D. Initiate cardiac monitoring.
Cardiac monitoring is important to assess for signs of cardiac compromise or dysrhythmias associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.
Correct Answer is B
Explanation
A. The spacer increases the amount of medication delivered to the oropharynx.
Spacers are designed to minimize the amount of medication deposited in the oropharynx (back of the throat) and reduce the risk of side effects such as oral thrush or hoarseness. The main purpose of using a spacer is to optimize the delivery of medication to the lungs.
B. The spacer increases the amount of medication delivered to the lungs.
When reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose inhaler (MDI) to treat asthma, the nurse should include the information that the spacer increases the amount of medication delivered to the lungs. Spacers help improve the delivery of medication from the MDI to the lungs by reducing the need for coordination between actuation of the MDI and inhalation. They also slow down the speed of the aerosolized medication particles, allowing more time for them to be inhaled into the lungs effectively.
C. Inhale rapidly when using the spacer with the MDI.
Inhaling rapidly may lead to improper inhalation technique and reduce the effectiveness of medication delivery to the lungs. Instead, the child should be instructed to inhale slowly and deeply to ensure that the medication reaches the lower airways.
D. Cover exhalation slots of the spacer with lips when inhaling.
Covering the exhalation slots of the spacer with lips during inhalation is not recommended. These slots are designed to allow the child to exhale freely and prevent buildup of pressure within the spacer. Encouraging the child to exhale into the spacer would hinder proper inhalation technique and could lead to decreased medication delivery to the lungs.
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