A patient is having dyspnea. What would the nurse do first?
Take the blood pressure
Remove the pillow from under the patient’s head
Elevate the foot of the bed
Elevate the head of the bed
The Correct Answer is A
A. Take the blood pressure:
Assessing blood pressure is a critical initial step when a patient is experiencing dyspnea. It helps provide information about the patient's overall cardiovascular status, which is essential in determining the severity of the dyspnea and guiding subsequent interventions.
B. Remove the pillow from under the patient’s head:
Removing the pillow may be a relevant intervention if the patient is in a position that could be contributing to respiratory distress. However, the priority is to first assess vital signs, particularly blood pressure, to gather information about the patient's cardiovascular status.
C. Elevate the foot of the bed:
Elevating the foot of the bed may be a consideration if the dyspnea is related to conditions such as heart failure, where raising the legs can help reduce venous return and decrease the workload on the heart. However, the initial priority is to assess blood pressure to guide appropriate interventions.
D. Elevate the head of the bed:
Elevating the head of the bed may be beneficial for patients with respiratory distress to improve ventilation and oxygenation. While this intervention may be appropriate, the first action should be to assess vital signs, particularly blood pressure, to gain an overall understanding of the patient's condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Regular deep respirations interspersed with periods of apnea:
This describes periodic breathing, which is different from Cheyne-Stokes respirations. Periodic breathing consists of regular cycles of deep respirations followed by periods of apnea.
B. A pattern of crescendo-decrescendo respirations followed by a period of apnea
Cheyne-Stokes respirations are characterized by a pattern of crescendo-decrescendo respirations, meaning that the depth and rate of breathing gradually increase and then decrease. This is followed by a period of apnea, during which there is a temporary cessation of breathing. The cycle then repeats.
C. Patient breathing less than 10 breaths per minute:
This describes bradypnea, which is an abnormally slow respiratory rate. Cheyne-Stokes respirations involve rhythmic, cyclical changes in respiratory rate and depth.
D. Patient breathing shallow and more than 24 breaths per minute:
This describes tachypnea, which is an abnormally fast respiratory rate. Cheyne-Stokes respirations are characterized by a distinct pattern of alternating crescendo-decrescendo respirations followed by apnea.
Correct Answer is A
Explanation
A. Documentation is a communication tool for the interprofessional health care team
The purpose of documentation in the electronic health record (EHR) includes serving as a communication tool among members of the interprofessional healthcare team. Accurate and timely documentation allows healthcare providers to share information about the client's care, treatment, and outcomes.
B. Documentation allows providers to monitor the nurse’s activities:
While documentation provides a record of the nurse's activities, the primary purpose is to communicate information about patient care rather than serving as a tool for monitoring the nurse's activities.
C. Documentation provides information to the client about financial charges:
The primary purpose of documentation is to record and communicate information about the client's health status, care, and outcomes. Financial information is typically managed separately from clinical documentation.
D. Documentation provides information for a client audit:
While documentation can be used in audits for quality assurance, the primary purpose is to record and communicate information about patient care. The use of documentation for audits is a secondary function related to quality improvement and regulatory compliance.
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