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 B
Explanation
Sit in a straight-backed chair. After a total hiparthroplasty, the client should avoid sitting in chairs that are too low or too soft, as they can be difficult to rise from and can risk dislocating the new hip. The clientshould apply ice to the incision site, not moist heat, in the first few dayspostoperatively. The client should avoid adducting the hip as this can also riskdislocation of the new hip joint. Hydrogen peroxide should not be used to cleanthe surgical incision, as it can delay wound healing.
Choice A: The client shouldapply ice to the incision site, not moist heat, in the first few days postoperatively.
Choice C: The client should avoid adducting the hip as this can risk dislocation ofthe new hip joint.
Correct Answer is A
Explanation
The correct answer is choice A, apply a motion sensor mat to the client's bed. This is an effective intervention to monitor the client's movements and prevent falls. The mat is placed under the bed sheet and will sound an alarm if the client tries to get out of bed.
- Moving the overbed table away from the bed is not the correct answer because it does not prevent falls.
- Raising all four side rails while the client is in bed is not the correct answer because it can cause the client to feel trapped and can lead to injuries if they try to climb over the rails.
- Leaving the television on in the client's room is not the correct answer because it can be distracting and interfere with the client's sleep.
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