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 B
Explanation
B. An elevated white blood cell (WBC) count, specifically an elevation in the neutrophil count (neutrophilia), is commonly seen in pneumonia. It indicates an inflammatory response to the infection and is a typical finding in bacterial pneumonia.
A. A decreased serum creatinine level is not typically associated with pneumonia and may not be directly related to the condition. In fact, it may suggest impaired kidney function or dehydration, but it is not a concerning lab abnormality specifically related to pneumonia.
C. Protein in the urine (proteinuria) may be present in various conditions, including kidney disease, urinary tract infections, and certain systemic illnesses. While it can sometimes be seen in severe cases of pneumonia, it is not a specific or common finding associated with the condition.
D. Decreased serum potassium levels are not typically associated with pneumonia itself. However, certain factors related to pneumonia treatment or complications, such as the use of diuretics or vomiting, could lead to hypokalemia. While hypokalemia can have serious consequences, it is not directly related to the severity of pneumonia.
Correct Answer is C
Explanation
C. Raisins are a source of carbohydrates, particularly simple sugars like glucose and fructose, which can quickly raise blood sugar levels during an episode of hypoglycemia. However, they do not contain protein, which can help sustain blood sugar levels over time. Raisins may provide a rapid increase in blood sugar but may not be as effective at preventing subsequent episodes of hypoglycemia.
A. Cheese is a source of protein and contains very little carbohydrate. While protein can help stabilize blood sugar levels, it may not provide a rapid increase in blood sugar during an episode of hypoglycemia. Cheese alone may not be the most effective choice for treating low blood sugar promptly.
B. Beef jerky is primarily a source of protein and may not contain enough carbohydrates to quickly raise blood sugar levels during an episode of hypoglycemia. While protein can help stabilize blood sugar over time, it may not provide the rapid increase in blood sugar needed to address acute hypoglycemia.
D. Chocolate, especially dark chocolate with a high cocoa content, contains carbohydrates in the form of sugar and fat. While it can quickly raise blood sugar levels due to its sugar content, it may not provide sustained energy due to its low protein content.
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