The nurse enters a room of a patient who is acutely short of breath. Which action should the nurse take first?
teach the patient the use of accessory muscles
ask the patient what caused the dyspnea
encourage the use of pursed lip breathing
assist the patient into a Sims position
The Correct Answer is C
C. Pursed lip breathing is a technique that can help patients with acute dyspnea by improving ventilation, prolonging exhalation, and reducing the work of breathing. It helps to keep the airways open longer and makes it easier to get rid of excess carbon dioxide, which can provide quick relief from acute shortness of breath.
A. Teaching the patient about using accessory muscles for breathing can be beneficial in managing chronic respiratory issues, but it is not an immediate intervention.
B. Understanding the cause of dyspnea is important for treatment planning but it is not the first action to take when the patient is experiencing acute shortness of breath.
D. The Sims position, where the patient lies on their side with the lower arm behind the back and the upper leg flexed, is not typically used for relieving acute respiratory distress.
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Related Questions
Correct Answer is A
Explanation
A. Holding the breath for at least 10 seconds after inhaling the medication allows the medication to settle in the lungs and increases its effectiveness. This ensures maximum delivery of the drug to the respiratory tract.
B. The recommended time to wait between inhalations is typically around 1 to 2 minutes, not 10 minutes. Waiting too long between puffs may reduce the effectiveness of the medication and is not necessary.
C. There is no specific recommendation that the inhaler must be held with the non-dominant hand. The inhaler should be held in the hand that feels most comfortable and provides the best control, which is usually the dominant hand for most people.
D. The correct technique involves tilting the head slightly back to open the airway, making it easier for the medication to reach the lungs. Tilting the head forward could restrict the airflow and reduce the effectiveness of the inhalation.
Correct Answer is D
Explanation
D. The priority focus in the acute management of hyperosmolar hyperglycemia is improving hydration status. Patients with HHS are severely dehydrated due to the osmotic diuresis caused by extremely high blood glucose levels. Rapid rehydration is critical to prevent shock, improve organ perfusion, and reduce blood glucose levels.
A. It's important to consider age-related changes in any patient but this is not the immediate priority in the acute management of hyperosmolar hyperglycemia. The primary concern is addressing the acute, life-threatening aspects of the condition.
B. Monitoring blood glucose levels is critical in managing hyperosmolar hyperglycemia. However, while it is essential to track the BG levels to guide insulin therapy and assess the response to treatment, it is not the immediate priority in terms of interventions needed to stabilize the patient initially.
C. Determining the underlying cause of hyperosmolar hyperglycemia, such as an infection or other illness, is important for comprehensive treatment. However, it is a secondary priority to stabilizing the patient’s current acute condition.
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