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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Refrain from using a tether strap on the car seat for children under 1 year of age: Tether straps are generally used for forward-facing car seats to reduce forward movement in a crash. Infants under 1 year should be in rear-facing seats, where tethers are not typically applicable, but the focus should be on proper rear-facing installation rather than avoiding tethers altogether.
B. Manual shoulder belts in the front seat are acceptable for school-age children over 8 years of age: Children under 13 years should ride in the back seat whenever possible, as front-seat placement increases the risk of injury from airbags and seat belts. Using front seats is not recommended solely based on age.
C. Restrict using rear-facing car seats for children after 1 year of age: Current guidelines recommend keeping children in rear-facing seats as long as possible, typically until at least age 2 or until they reach the height and weight limits of the rear-facing seat. Restricting rear-facing use at 1 year is outdated and unsafe.
D. Booster seats with belt-positioning should be used for school-age children until 8 years of age: Booster seats help position the seat belt correctly over a child’s shoulder and lap, reducing the risk of injury in a crash. This is consistent with current safety guidelines and supports proper seat belt use until the child is tall enough and meets weight requirements for adult seat belts.
Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"C"},"C":{"answers":"A,C"},"D":{"answers":"A,B,C"},"E":{"answers":"A,B,C"}}
Explanation
Rationale
• Diarrhea: Diarrhea is common in both ulcerative colitis and Crohn's disease because chronic inflammation disrupts absorption and increases motility. UC typically presents with bloody diarrhea, while Crohn’s can present with non-bloody, intermittent diarrhea. Diverticulitis more often presents with left-lower-quadrant pain and constipation rather than chronic diarrhea.
• Steatorrhea: Steatorrhea is strongly associated with Crohn’s disease due to small-bowel involvement leading to fat-malabsorption. UC affects only the colon and does not impair fat absorption, so steatorrhea is not expected. Diverticulitis is a localized colonic infection and does not interfere with digestion or absorption.
• Weight loss: Weight loss occurs in both UC and Crohn’s because chronic inflammation increases metabolic demand and reduces nutritional intake. Malabsorption in Crohn’s disease further contributes to weight loss severity. Weight loss is not typical in diverticulitis unless the condition is prolonged or severe, so it is not strongly associated.
• Anemia: Anemia appears in both UC and Crohn’s disease due to chronic blood loss, reduced intake, and inflammation-driven suppression of erythropoiesis. UC often causes iron-deficiency anemia from recurrent rectal bleeding. Crohn’s may also cause anemia due to B12 or iron malabsorption. Diverticulitis does not typically cause chronic anemia.
• Fever: Fever is a sign of active inflammation and can occur in UC, Crohn’s flares, and acute diverticulitis. UC and Crohn’s involve systemic inflammatory activity during exacerbations. Diverticulitis produces fever due to infection of the diverticulum, making fever consistent across all three in varying degrees.
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