The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

Left lateral position.

Reverse Trendelenburg.

High-Fowler's position.

Supine

Answer and Explanation

The Correct Answer is C

A)   Incorrect- The left lateral position might not provide enough lung expansion for a client in respiratory distress.
B)   Incorrect- Reverse Trendelenburg (head of bed elevated, foot of bed lowered) might not provide enough lung expansion and could exacerbate respiratory distress.
C)   Correct- The High-Fowler's position, where the client is sitting upright at a 90-degree angle or as upright as tolerated, helps to improve lung expansion, reduce pressure on the diaphragm, and promote optimal oxygenation. This position is commonly used for clients with respiratory distress.
D)   Incorrect- The supine position may worsen pulmonary congestion and compromise lung expansion in clients with pulmonary edema.

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Correct Answer is A

Explanation

Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.

Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.

A. Encourage the use of ice on the areola. B. Teach about the use of a breast pump. C. Offer supplemental formula feedings. D. Recommend using a breast shield.

Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: Ice application induces vasoconstriction, which reduces swelling but does not evert inverted nipples. This action does not address the primary issue of nipple inversion preventing adequate latch.

Choice B rationale: Breast pump use creates negative pressure, drawing out the nipple. This eversion facilitates latching by providing a more prominent nipple for the infant's oral cavity to grasp effectively.

Choice C rationale: Supplemental formula feedings provide nutrition, but do not resolve the latching difficulty caused by inverted nipples. This can interfere with the establishment of the mother's milk supply.

Choice D rationale: Breast shields can aid latching, but they are most effective when used in conjunction with nipple eversion techniques. They do not directly address the underlying problem of inverted nipples.

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The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

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Naxlex Comprehensive Predictor Exams

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