A patient is admitted to the hospital with SOB. The nurse notices increasing confusion and combativeness during the past hour. Which of the following actions is appropriate first?

Assess the patient; check to see if the oxygen is flowing correctly

Page the MD STAT

Put up the patient's side rails and apply soft restraints

Administer an IM sedative

Answer and Explanation

The Correct Answer is A

A. Assess the patient; check to see if the oxygen is flowing correctly:

This option involves assessing the patient's condition promptly, particularly focusing on the adequacy of oxygenation. Checking the oxygen delivery system ensures that the patient is receiving the prescribed oxygen therapy at the appropriate flow rate. In a patient with shortness of breath (SOB) and increasing confusion and combativeness, hypoxemia (low oxygen levels) could be a contributing factor. Therefore, assessing the oxygen delivery system is crucial to ensure proper oxygenation and address potential causes of the patient's symptoms.

B. Page the MD STAT:

Paging the MD STAT may be necessary after assessing the patient's condition, especially if the patient's symptoms indicate a medical emergency or require immediate intervention. However, in this scenario, the priority is to assess the patient's condition and address any immediate concerns related to oxygenation and respiratory status. While paging the healthcare provider may be necessary, it should not delay the initial assessment and interventions needed to stabilize the patient.

C. Put up the patient's side rails and apply soft restraints:

Applying side rails and soft restraints should not be the first action in response to the patient's symptoms. While patient safety is important, these measures should only be implemented after other interventions have been attempted, and there is a risk of harm to the patient or others due to agitation or combativeness. In this case, the patient's confusion and combativeness may be secondary to hypoxemia, so addressing oxygenation and assessing the patient's condition are the immediate priorities.

D. Administer an IM sedative:

Administering a sedative should not be the first action in this scenario. Sedation may be considered if the patient's agitation or combativeness poses a risk to their safety or interferes with assessment and treatment. However, the underlying cause of the patient's symptoms, such as hypoxemia, should be addressed first. Administering a sedative without addressing the potential cause of the patient's symptoms could mask important clinical indicators and delay appropriate treatment.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Rest in a supine position.

This option is not recommended for improving gas exchange in emphysema. Resting in a supine position can lead to decreased lung expansion and increased dyspnea in individuals with emphysema. Optimal lung expansion is crucial for efficient gas exchange, and certain positions, such as sitting upright or using pillows to support the head and chest, are preferred to facilitate breathing.

B. Consume a low-protein diet.

A low-protein diet is not directly related to improving gas exchange in emphysema. In fact, adequate protein intake is important for maintaining overall health and supporting respiratory muscle function. Protein is necessary for tissue repair and maintaining muscle strength, including the respiratory muscles. Therefore, a balanced diet that includes adequate protein intake is recommended for individuals with emphysema.

C. Breathe in through her nose and out through pursed lips.

This is the correct choice. Breathing in through the nose and out through pursed lips helps to create positive pressure in the airways during exhalation. This positive pressure helps to keep the airways open, prevents premature collapse of the air sacs (alveoli), and facilitates more effective gas exchange. It also slows down the rate of breathing, reduces the work of breathing, and can alleviate shortness of breath (dyspnea) in individuals with emphysema.

D. Limit fluid intake throughout the day.

Limiting fluid intake throughout the day is not recommended for improving gas exchange in emphysema. Adequate hydration is important for thinning respiratory secretions, which can make it easier to clear mucus from the airways. Dehydration can worsen respiratory symptoms and increase the risk of complications. Therefore, maintaining adequate fluid intake is essential for individuals with emphysema.

A. Treatment is not needed if the client is asymptomatic. B. Treatment is not needed if the pulmonary embolism is intermediate. C. Treatment is not needed if the client is hemodynamically stable. D. Treatment is needed for all clients who have a pulmonary embolism.

Correct Answer is D

Explanation

A. Treatment is not needed if the client is asymptomatic.

Even asymptomatic pulmonary embolisms can lead to complications such as progression to symptomatic PE or development of chronic thromboembolic pulmonary hypertension. Therefore, treatment is necessary to prevent these complications.

B. Treatment is not needed if the pulmonary embolism is intermediate.

The severity of a pulmonary embolism is determined by various factors, including the size and location of the clot and the degree of obstruction in the pulmonary arteries. Intermediate-risk pulmonary embolisms still require treatment to prevent complications and reduce the risk of progression to a more severe or life-threatening condition.

C. Treatment is not needed if the client is hemodynamically stable.

Hemodynamic stability refers to the client's circulatory status and whether they are maintaining adequate blood flow to vital organs. While hemodynamically stable clients may not require aggressive interventions such as thrombolytic therapy or surgical embolectomy, they still require anticoagulant therapy to prevent further clot formation and reduce the risk of complications.

D. Treatment is needed for all clients who have a pulmonary embolism.

Pulmonary embolism (PE) is a serious and potentially life-threatening condition that requires prompt treatment. Regardless of the severity of symptoms or the client's hemodynamic stability, treatment is necessary to prevent complications and reduce the risk of recurrence. Treatment typically includes anticoagulant therapy to prevent further clot formation and may include additional interventions such as thrombolytic therapy or surgical interventions in certain cases.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A patient is admitted to the hospital with SOB. The nurse notices increasing confusion and combativeness during the past hour. Which of the following actions is appropriate first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching for a client who presents with a pulmonary embolism. Which of the following information should the nurse provide?

Correct Answer is D

Explanation

Which patient(s) would be able to take an alpha-adrenergic decongestant safely? (SELECT ALL THAT APPLY)

A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse enters a client's room to administer medication and finds the client lying in bed disoriented with labored and fast respirations. Which of the following actions should the nurse take first?

A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?

A nurse is reinforcing teaching with a client who is to start taking montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?