A patient hospitalized with a myocardial infarction suddenly begins having severe respiratory distress with frothy red sputum. What is the first action for the nurse to take?
Notify the patient's family.
Provide oxygen as prescribed.
Notify the health care provider.
Elevate the head of the bed.
The Correct Answer is B
Choice A Reason:Notifying the patient's family is not the immediate priority when the patient is experiencing severe respiratory distress. The nurse's primary focus should be on addressing the patient's acute symptoms.
Choice B Reason:Providing oxygen is crucial in managing respiratory distress. In a patient with myocardial infarction (heart attack), adequate oxygenation is essential to prevent further complications. The nurse should promptly administer oxygen as prescribed to improve oxygen supply and alleviate distress.
Choice C Reason:While notifying the health care provider is essential, it is not the first action in this critical situation. The nurse should prioritize interventions that directly address the patient's distress.
Choice D Reason:Elevating the head of the bed (semi-Fowler's position) is beneficial for patients with respiratory distress, but it is not the initial action. Providing oxygen takes precedence over positioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Anger towards a deceased spouse can be a sign of unresolved grief and may indicate complicated grief or depression, requiring further intervention.
Choice B reason: Reestablishing relationships is a positive step in coping with loss and suggests progress in managing grief.
Choice C reason: Although it's difficult, the effort to engage with the community is a positive sign of coping and does not typically indicate a need for further intervention.
Choice D reason: A lack of desire to eat due to the absence of a loved one can be a normal part of grieving, but if persistent, it may require intervention to address potential depression.
Correct Answer is C
Explanation
Choice A Reason:Encouraging the client to rest in bed until she feels able to participate in unit activities is appropriate. Depression often leads to fatigue, lack of motivation, and decreased interest in daily activities. Allowing the client to rest and regain energy while acknowledging her feelings is supportive and respectful.
Choice B Reason:Telling the client that she needs to follow the rules of the unit and get out of bed may come across as dismissive and unsupportive. It does not consider the client's emotional state or address her fatigue. A more empathetic approach is needed.
Choice C Reason:Offering assistance to help the client sit up and put on her slippers is a helpful action, but it does not directly address her feelings of tiredness or depression. While physical support is essential, emotional support and understanding are equally crucial.
Choice D Reason:Linking getting out of bed to receiving a meal may inadvertently pressure the client. It could worsen her feelings of guilt or hopelessness. Instead, focusing on her well-being and emotional state is more appropriate.
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