A patient is experiencing dyspnea.
Which intervention(s) would the nurse implement for the patient? Select all that apply.
Encourage the patient to use an incentive spirometer.
Auscultate lung sounds bilaterally.
Ambulate the patient in the hall.
Position the bed in high fowlers.
Assess the pulse oximetry.
Correct Answer : A,B,D,E
Choice A rationale:
Encourage the patient to use an incentive spirometer. Rationale: Encouraging the use of an incentive spirometer helps improve lung function and prevent respiratory complications. It promotes deep breathing and prevents atelectasis, especially in patients experiencing dyspnea.
Choice B rationale:
Auscultate lung sounds bilaterally. Rationale: Auscultating lung sounds helps the nurse assess for abnormal breath sounds, such as wheezing or crackles, which can indicate respiratory distress. This assessment is crucial in managing a patient with dyspnea.
Choice C rationale:
Ambulate the patient in the hall. Rationale: Ambulating the patient can worsen dyspnea in some cases, especially if the patient is experiencing severe respiratory distress. Therefore, this intervention may not be appropriate for a patient with dyspnea.
Choice D rationale:
Position the bed in high fowlers. Rationale: Positioning the patient in high fowlers (sitting upright with the head of the bed elevated) helps improve lung expansion and ease breathing. This position maximizes the patient's lung capacity and can provide relief from dyspnea.
Choice E rationale:
Assess the pulse oximetry. Rationale: Monitoring pulse oximetry levels is essential in assessing the patient's oxygen saturation. It helps the nurse determine if the patient is receiving adequate oxygenation, which is crucial in managing dyspnea. A normal oxygen saturation range is typically 95% to 100%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
Choice A rationale:
The nurse verifies the recipient's fax number before faxing private patient information. This action is appropriate and ensures that patient information is sent to the correct recipient, maintaining patient confidentiality and privacy. Verifying recipient information is a standard practice in healthcare settings to prevent data breaches.
Choice B rationale:
The nurse documents the patient assessment using objective data. This action is appropriate and follows evidence-based practice guidelines. Objective data are measurable and observable, providing a clear picture of the patient's condition. Objective documentation enhances communication among healthcare providers and ensures accurate representation of the patient's status.
Choice C rationale:
The nurse posts the obituary of a patient on social media. This action is highly inappropriate and unethical. It breaches patient confidentiality and privacy, violating the Health Insurance Portability and Accountability Act (HIPAA) regulations. Sharing patient information, especially sensitive details like an obituary, on social media platforms is a serious violation of privacy and can lead to legal consequences.
Choice D rationale:
The nurse discards copies of patient information into the regular trash bin. This action is inappropriate and violates patient confidentiality. Proper disposal of patient information is crucial to protect patient privacy and comply with regulations. Patient documents should be shredded or disposed of in designated secure bins to prevent unauthorized access to sensitive information.
Choice E rationale:
The nurse accesses the nurse's own health record via computer. This action is inappropriate unless there is a legitimate reason related to patient care. Accessing one's own health record without a valid purpose is a breach of patient privacy and can lead to disciplinary actions. Healthcare professionals should only access patient records when necessary for providing care and treatment.
Correct Answer is C
Explanation
Choice A rationale:
Ethical dilemma involves a situation in which a person is faced with conflicting moral principles, making it difficult to choose the right course of action. In this scenario, the nurse is not dealing with conflicting moral principles but rather providing information about end-of-life care options, demonstrating respect for the patient's autonomy.
Choice B rationale:
Nonmaleficence is the principle of doing no harm. While it is an important ethical principle in nursing, it does not directly apply to the situation described. The nurse is not making decisions that could harm the patient but is instead providing information and support regarding end-of-life care options.
Choice C rationale:
Autonomy refers to the right of individuals to make their own decisions about their own lives and bodies, even if those decisions are not in their best interest according to others. In this scenario, the nurse is respecting the patient's autonomy by providing information and discussing various care options, allowing the patient to make informed decisions about their end-of-life care.
Choice D rationale:
Social justice involves promoting fairness and equity in the distribution of resources and opportunities. While social justice is an important nursing value, it does not directly apply to the situation described. The nurse is primarily focused on respecting the patient's autonomy and providing information about end-of-life care options.
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