Based on the information provided, what is the most appropriate initial nursing action?
Increase the oxygen flow rate.
Administer an additional dose of furosemide.
Notify the healthcare provider.
Reposition the client to a high Fowler’s position.
The Correct Answer is D
Choice A rationale:
Increasing the oxygen flow rate may help improve oxygen saturation, but it does not address the underlying issue of fluid overload and heart failure exacerbation.
Choice B rationale:
Administering an additional dose of furosemide may help reduce fluid overload, but it is not the most immediate action to improve the client’s respiratory status and comfort.
Choice C rationale:
Notifying the healthcare provider is important, but the nurse should first take immediate action to improve the client’s respiratory status and comfort.
Choice D rationale:
Repositioning the client to a high Fowler’s position is the most appropriate initial nursing action. This position helps improve lung expansion and reduces the work of breathing, providing immediate relief for the client experiencing dyspnea and respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.
Choice B rationale:
Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.
Choice C rationale:
Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.
Choice D rationale:
Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.
Choice E rationale:
Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.
Choice F rationale:
Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Increased crying episodes are a common indicator of pain in infants. Crying is a behavioral response to discomfort and can be more intense or frequent when the infant is in pain. This response is due to the activation of the infant’s nervous system, which signals distress through crying.
Choice B rationale
Decreased respiratory rate is not typically associated with pain in infants. Pain usually causes an increase in respiratory rate due to the body’s stress response, which involves the release of adrenaline and other stress hormones that stimulate the respiratory system.
Choice C rationale
Decreased heart rate is also not a common sign of pain in infants. Pain generally leads to an increased heart rate as part of the body’s fight-or-flight response, which is mediated by the sympathetic nervous system.
Choice D rationale
Increased formula consumption is not an indicator of pain. In fact, pain might reduce an infant’s appetite and lead to decreased feeding. Pain can cause discomfort during feeding, leading to fussiness and refusal to eat.
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