A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?
Place the client in high-Fowler's position.
Obtain the client's vital signs.
Administer heparin to the client.
Encourage the client to cough and deep breathe.
The Correct Answer is A
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Place white tape on the edges of stairs.
Choice A rationale:
While having the furnace inspected is important for safety, it should be done annually, not every two years.Regular inspections help prevent carbon monoxide leaks and ensure the furnace is functioning properly.
Choice B rationale:
Running wires and cords under carpeting is a safety hazard. It can lead to overheating and potentially cause a fire.Additionally, it creates a tripping hazard.
Choice C rationale:
Placing white tape on the edges of stairs is a recommended safety measure.It increases visibility, especially for older adults who may have vision impairments, reducing the risk of falls.
Choice D rationale:
Placing area rugs on wooden floors can be dangerous as they can slip and cause falls.If area rugs are used, they should be secured with non-slip backing or tape.
Correct Answer is D
Explanation
The correct answer is choice D. Provide regular oral care for the client with a moist swab. When a client with a terminal illness and in the active phase of dying refuses further hydration and nourishment, the nurse should provide comfort measures such as regular oral care to prevent discomfort. The nurse should not force the client to eat or drink or request a prescription for IV fluids. The healthcare surrogate cannot be asked for permission to withhold nourishment as the client has the right to refuse nourishment.
Option A - The client has the right to refuse nourishment, and healthcare surrogate permission is not required.
Option B - Requesting a prescription for IV fluids is not an appropriate intervention as the client has the right to refuse nourishment.
Option C - Explaining the importance of oral hydration to the client is not an appropriate intervention as the client has the right to refuse nourishment.
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