A nurse is performing a mobility assessment on a client.
Which of the following actions should the nurse take first?

Choice A rationale:

Increasing the heat in the client's room is not the appropriate action for managing dyspnea. Dyspnea, or difficulty breathing, is not typically related to room temperature. Other interventions should be prioritized.

Choice B rationale:

Performing nasotracheal suctioning for the client is not the initial action to address dyspnea at the end of life. Suctioning is indicated when there is excessive secretions or airway obstruction but should not be the first intervention for dyspnea.

Choice C rationale:

Placing the head of the client's bed flat is not the best action for a client experiencing dyspnea. Elevating the head of the bed (Fowler's position) is the recommended position to improve lung expansion and reduce dyspnea in clients with breathing difficulties.

Choice D rationale:

Administering an opioid narcotic to the client is the most appropriate action for managing dyspnea at the end of life. Opioid medications, such as morphine, are often used to relieve severe dyspnea in hospice and palliative care settings. These medications can help relax the client and reduce the sensation of breathlessness. .

Choice A rationale:

Holding the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating is not the best practice for wound irrigation. It's crucial to maintain a close distance to the wound to ensure that the irrigation solution effectively cleans the area.

Choice B rationale:

Chilling the irrigant prior to the procedure is not necessary and could be uncomfortable for the patient. Room temperature or slightly warmed sterile saline solution is typically used for wound irrigation to prevent temperature-related discomfort.

Choice C rationale:

Flushing the wound from the most contaminated area to the cleanest area is an incorrect approach for wound irrigation. The wound should be irrigated from the cleanest to the most contaminatedto prevent contamination of previously clean areas and ensures thorough cleaning of the wound.

Choice D rationale:

Irrigating the wound until the solution that is draining is clear is a common practice for wound irrigation. It indicates that the wound is free of contaminants, debris, and infectious material.