A nurse is caring for a client in the emergency department.

Which of the following interventions should the nurse include in the plan of care? Select all that apply.

Place the client in a supine position.

Instruct the client to perform diaphragmatic breathing.

Increase oxygen flow rate to 4 L/min.

Assess the client's breath sounds.

Restrict the client's fluid intake.

Perform chest percussion and vibration.

Answer and Explanation

Correct Answer : B,D,F

A. Place the client in a supine position: The supine position can worsen dyspnea by limiting diaphragmatic movement and decreasing lung expansion. Clients with respiratory distress should be positioned upright or semi-Fowler’s to facilitate breathing.

B. Instruct the client to perform diaphragmatic breathing: Diaphragmatic breathing helps improve oxygenation and ventilation by promoting deeper, more efficient breaths. It also reduces accessory muscle use and can decrease anxiety associated with shortness of breath.

C. Increase oxygen flow rate to 4 L/min: Oxygen should be titrated to maintain target saturation (usually 92–94% for COPD risk patients). The client’s current oxygen saturation is 92% on 2 L/min, so increasing the flow is unnecessary at this time.

D. Assess the client's breath sounds: Ongoing assessment of breath sounds is essential to monitor for changes such as wheezing, crackles, or diminished air entry, which guide interventions and evaluate response to therapy.

E. Restrict the client's fluid intake: Fluid restriction is not indicated in this client’s current presentation. Adequate hydration helps thin secretions, making coughing and airway clearance more effective.

F. Perform chest percussion and vibration: Chest physiotherapy techniques like percussion and vibration can help loosen and mobilize secretions, improving airway clearance in clients with productive cough and retained secretions.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

A. Urine protein: The presence of 3+ protein in the urine is abnormal and indicates significant proteinuria, which is a key sign of preeclampsia. Monitoring protein levels is essential for detecting kidney involvement and assessing maternal and fetal risk.

B. Report of headache: A severe headache unrelieved by acetaminophen in a pregnant client with elevated blood pressure is a concerning symptom of preeclampsia. It can indicate cerebral involvement and increased risk for complications such as eclampsia or stroke.

D. Fetal activity: Decreased fetal movement is an important sign of potential fetal compromise. Reduced activity may indicate fetal distress or hypoxia, requiring prompt assessment and possible intervention.

E. Blood pressure: A blood pressure reading of 162/112 mm Hg is significantly elevated and meets criteria for severe preeclampsia. Hypertension during pregnancy can lead to maternal and fetal complications, making this a critical finding to address immediately.

A. Headache B. Vomiting C. Confusion D. Sedation E. Sweating

Correct Answer is ["A","B","C","E"]

Explanation

A. Headache: Disulfiram causes an aversive reaction when alcohol is consumed, leading to vasodilation and increased acetaldehyde levels. This often results in a severe, throbbing headache as one of the earliest and most common manifestations. The symptom appears quickly after alcohol intake and signals a disulfiram–alcohol interaction.

B. Vomiting: Accumulation of acetaldehyde triggers gastrointestinal distress, including nausea and profuse vomiting. These symptoms occur because the body is unable to metabolize alcohol properly while on disulfiram. Vomiting is a classic indicator that alcohol was consumed after starting therapy.

C. Confusion: Neurological effects such as confusion can develop during a disulfiram–alcohol reaction due to hypotension, decreased cerebral perfusion, and heightened toxin buildup. This change in mental status is especially concerning and suggests significant physiological stress after alcohol ingestion.

D. Sedation: Sedation is not a typical effect of a disulfiram–alcohol reaction. It is more commonly associated with other CNS depressants or alcohol intoxication alone. Because it does not reflect the vasodilatory or metabolic effects produced by disulfiram, it is not a reliable indicator of concurrent alcohol use.

E. Sweating: Sweating results from the sympathetic surge that occurs when acetaldehyde levels rise during a disulfiram–alcohol reaction. Clients may experience flushing, tachycardia, and diaphoresis as part of the acute response. This strongly supports that alcohol was consumed while taking disulfiram.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client in the emergency department. Which of the following interventions should the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is pregnant. The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

Correct Answer is ["A","B","D","E"]

Explanation

A nurse in an outpatient clinic is caring for a client. Select the 4 findings that indicate the client has been consuming alcohol while taking the newly prescribed medication.

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is assessing a client who is using crutches as an assistive device due to a right hip fracture. Which of the following actions should the nurse take prior to planning the client's care?

A nurse is caring for a client who wants to leave the facility against medical advice. In an attempt to prevent the client from leaving, an assistive personnel (AP) has hidden the client's car keys. Which of the following torts is the AP committing by hiding the client's car keys?

A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take?

A nurse in an emergency department is triaging clients following an external natural disaster. Which of the following clients should the nurse identify to receive care first?

A nurse manager is teaching a group of nurses about bacterial meningitis. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?

A nurse on a mental health unit is caring for a client. Complete the following sentence by using the lists of options. The client is at risk for _____ as evidenced by the client's _____ .

A nurse is caring for a client who is about to be discharged to a rehabilitation facility after knee surgery. Which of the following interventions should the nurse expect to find in the client's care plan?

A nurse is caring for a client in the emergency department.

Which of the following interventions should the nurse include in the plan of care? Select all that apply.