A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
Provide oral care to the client once every 8 hr.
Reposition the client once every 4 hr.
Place the head of the client's bed flat.
Use a fan to circulate air in the client's room.
The Correct Answer is B
Rationale for A: Providing oral care once every 8 hours is not directly related to relieving dyspnea. Oral care addresses comfort related to dry mouth, but it doesn't improve breathing difficulties.
Rationale for B: Repositioning the client every 4 hours can help alleviate dyspnea by improving lung expansion and preventing pooling of secretions. It also helps in reducing pressure injuries, promoting comfort, and preventing complications.
Rationale for C: Placing the head of the bed flat can exacerbate dyspnea by hindering lung expansion. It is recommended to elevate the head of the bed to improve air exchange and breathing.
Rationale for D: While using a fan can help with the sensation of breathlessness, repositioning every 4 hours is a more direct action to support ventilation and reduce dyspnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Documenting the status of the episiotomy, including its size and approximation, is important for monitoring wound healing and ensuring appropriate postpartum care.
B. While providing self-care instructions is important, it is not a specific documentation related to the postpartum condition.
C. Fluid intake with meals is important for overall health but may not be specifically related to the postpartum condition.
D. Documenting an elevated oral temperature may be relevant for assessing the client's health status but is not specific to the postpartum condition.
Correct Answer is C
Explanation
Rationale:
A. Telling the client that it is safe to touch her ostomy may not address the client's concerns or fears.
B. Requesting that someone from the client's family participate in the care may not address the client's concerns or fears.
C. Asking the client to explain her feelings allows the nurse to understand the client's concerns or fears and address them appropriately.
D. Explaining why her participation is important may not address the client's concerns or fears.
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