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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A, B, C, D, E
Explanation
A. Shake the canister 3 to 5 seconds vigorously.
Before each use, it's important to shake the MDI to ensure proper mixing of the medication.
B. Place her lips firmly around the mouthpiece.
Creating a tight seal around the mouthpiece ensures that the medication is delivered directly into the airways.
C. Inhale slowly over 3 to 5 seconds while pushing down on the canister.
While pressing down on the canister, the client should inhale slowly to allow the medication to reach the lungs.
D. Hold her breath for 10 seconds.
After inhaling the medication, holding the breath for 10 seconds allows for better absorption of the medication into the lungs.
E. Exhale slowly through pursed lips.
After holding the breath, exhaling slowly through pursed lips helps to fully exhale and ensures that the medication remains in the airways.
Correct Answer is D
Explanation
D. The primary cause of peptic ulcer disease is infection with Helicobacter pylori (H. pylori) bacteria. H. pylori infection is associated with the majority of peptic ulcers, particularly those in the stomach. This bacterium weakens the protective mucous lining of the stomach and duodenum, allowing stomach acid to damage the underlying tissue and form ulcers.
A. Spicy foods can exacerbate symptoms in some individuals with peptic ulcer disease but they are not a primary cause of the condition. Spicy foods can irritate the lining of the stomach or duodenum, potentially worsening symptoms, but they do not directly cause ulcers.
B. Stress was once thought to be a major factor in the development of peptic ulcers, but research has shown that while stress may aggravate symptoms, it is not a primary cause of peptic ulcer disease.
C. Excessive caffeine intake was also previously believed to be a major cause of peptic ulcer disease, but this is not entirely accurate. While caffeine can stimulate gastric acid secretion, leading to increased acidity in the stomach, it is not a primary cause of peptic ulcers.
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