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

Answer and Explanation

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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Correct Answer is C

Explanation

C. This patient is at high risk for hospital-acquired pneumonia. After a splenectomy (removal of the spleen), patients may experience pain and discomfort, which can make them reluctant to perform necessary activities like coughing and deep breathing. These activities are crucial for preventing lung complications such as atelectasis and pneumonia.
A. This patient is actively using an incentive spirometer, which is a device that encourages deep breathing and helps keep the lungs clear. This practice significantly reduces the risk of developing pneumonia by preventing atelectasis (collapse of part of the lung) and promoting lung expansion.

B. This patient is out of bed and eating, which indicates they are relatively mobile and maintaining normal respiratory function. Rhinoplasty, a surgical procedure on the nose, generally does not impair lung function or significantly increase the risk of pneumonia. Being active and upright further reduces the risk of HAP.
D. This patient is actively ambulating, which is highly beneficial for lung function and overall recovery. Walking and moving around helps to prevent respiratory complications, including pneumonia, by promoting lung expansion and circulation.

A. Consuming low-fat meats B. Drinking orange juice regularly C. Eating dinner early in the evening D. Sleeping on a large wedge-style pillow

Correct Answer is B

Explanation

B. Orange juice is highly acidic and can irritate the esophagus, leading to increased heartburn symptoms. Regular consumption of acidic beverages like orange juice can exacerbate GERD symptoms, making this a likely contributing factor to the client's heartburn.
A. Consuming low-fat meats is generally not a contributing factor to heartburn. Low-fat meats are less likely to cause reflux compared to high-fat foods, which can relax the lower esophageal sphincter and increase the risk of acid reflux.
C. Eating dinner early in the evening is generally recommended for managing GERD. This practice allows more time for the stomach to empty before lying down to sleep, reducing the likelihood of acid reflux during the night.
D. Sleeping on a large wedge-style pillow is also generally recommended for managing GERD. Elevating the head and upper body during sleep can help prevent acid from flowing back into the esophagus.

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The nurse enters a room of a patient who is acutely short of breath. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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