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 B
Explanation
Rationale:
A. A client who has rubella may be at risk for acquiring varicella from the client with herpes zoster.
B. A client who has had varicella is immune to varicella and is not at risk for acquiring herpes zoster from the client.
C. A client who is HIV-positive may be at risk for acquiring varicella from the client with herpes zoster.
D. A client who has tuberculosis may be at risk for acquiring varicella from the client with herpes zoster.
Correct Answer is B
Explanation
Rationale:
A. A stoma that protrudes slightly from the abdomen is normal after colostomy surgery.
B. A stoma that appears dark in color may indicate compromised blood flow and should be reported to the provider.
C. A stoma that bleeds lightly when touched is normal after colostomy surgery.
D. A stoma that is draining a small amount of liquid stool is normal after colostomy surgery.
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