A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
Assist the client to Fowler's position
Promote removal of pulmonary secretions
Increase the oxygen flow
Obtain a specimen for arterial blood gases
The Correct Answer is A
A. Assist the client to Fowler's position: This position helps maximize lung expansion, making it easier for the client to breathe.
B. Promote removal of pulmonary secretions: Important but secondary to addressing immediate respiratory distress.
C. Increase the oxygen flow: This should only be done per provider order to avoid complications such as oxygen toxicity.
D. Obtain a specimen for arterial blood gases: This is a diagnostic step but not an immediate intervention for difficulty breathing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. More than 250 mL of air moves in and out of the lungs with each breath: This describes tidal volume but does not directly stimulate the cough mechanism.
B. Foreign substances are propelled by the cilia toward the respiratory tract: Irritation by foreign particles stimulates the cough reflex to clear the airways.
C. Dehumidified air enters the upper airway passages: Dry air can cause airway irritation but does not consistently trigger a cough reflex.
D. The blood transports carbon dioxide to the lungs: This describes gas exchange, which does not directly relate to triggering the cough mechanism.
Correct Answer is B
Explanation
A. Food: More common in conscious individuals who are eating.
B. Tongue: The tongue can fall back and block the airway in an unconscious person.
C. Foreign object: Possible but less common than the tongue in unconscious individuals.
D. Medication in pill form: Rare cause of airway obstruction.
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