The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?

Measure the vital signs.

Assist to a high Fowler's position.

Initiate deep breathing exercises.

Auscultate breath sounds.

Answer and Explanation

The Correct Answer is B

Rationale

A. Measuring vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, is important to assess the client's overall status and to determine the severity of the dyspnea. Vital signs provide essential information to guide further interventions. While important, this action may not directly alleviate the client's immediate distress from dyspnea.

B. Placing the client in a high Fowler's position (sitting upright with the head of the bed elevated to 90 degrees) helps to maximize chest expansion and improve lung ventilation. This position can relieve dyspnea by reducing pressure on the diaphragm and improving lung compliance. It is a simple and effective intervention for clients experiencing respiratory distress.

C. While deep breathing exercises are beneficial for promoting lung expansion and improving respiratory function, they may not be appropriate as the first action when the client is already dyspneic. The priority

should be to position the client to alleviate immediate breathing difficulty before initiating exercises that require active participation.

D. Auscultating breath sounds is important for assessing lung function and detecting any abnormalities such as adventitious sounds (e.g., crackles, wheezes). However, this action is secondary to placing the client in a high Fowler's position to relieve dyspnea. Auscultation can be performed after the client's breathing has stabilized.

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Free Nursing Study Resources

Correct Answer is "{\"xRanges\":[389.5,439.5],\"yRanges\":[222,272]}"

Explanation

Site- the nose

Rationale

Rhinorrhea refers specifically to cerebrospinal fluid (CSF) rhinorrhea. This occurs when there is a leakage of CSF from the nose due to a fracture or injury to the skull base or surrounding structures, such as the cribriform plate.

CSF is a clear fluid that surrounds and cushions the brain and spinal cord. When there is a fracture or disruption in the skull base, CSF can leak out through the nasal passages. This condition is concerning because it can increase the risk of infection, such as meningitis, due to the direct communication between the central nervous system and the external environment through the nasal cavity.

A. Notify primary healthcare provider B. Count saturated pads per hour C. Administer 2 units of packed red blood cells (PRBC) D. Administer 0.2 mg methylergonovine IM E. Insert straight catheter F. Alert the emergency response team G. Increase the IV fluid to maximum rate H. Weigh all bloody materials I. Massage fundus until firm

Correct Answer is ["A","B","D","F","G","I"]

Explanation

A.Notify primary healthcare provider
The client's vital signs indicate signs of potential hypovolemic shock (low blood pressure, tachycardia, fever), and the saturated pad and sheets suggest ongoing significant bleeding. Notifying the primary healthcare provider is crucial to obtain further orders and potentially escalate care.
B. Count saturated pads per hour
Counting saturated pads per hour provides a quantitative assessment of blood loss and helps monitor the effectiveness of interventions aimed at reducing bleeding. This ongoing assessment guides further management decisions.
C. Administer 2 units of packed red blood cells (PRBC)

While blood loss is significant, initiating a blood transfusion is not typically an immediate first-line intervention unless the client shows signs of severe hemorrhagic shock or ongoing bleeding that cannot be controlled by other measures.
D. Administer 0.2 mg methylergonovine IM
Methylergonovine is a medication used to promote uterine contraction and control postpartum hemorrhage. Given the boggy fundus and significant bleeding, administering methylergonovine IM helps to contract the uterus and reduce bleeding.
E. Insert straight catheter
While maintaining accurate fluid balance is important, inserting a straight catheter is not an immediate priority compared to addressing active hemorrhage and stabilizing the client's condition.
F. Alert the emergency response team
The client's condition, with a boggy fundus, saturated pads, and ongoing bleeding, indicates a need for urgent intervention beyond routine measures. Alerting the emergency response team ensures prompt assistance and resources for managing potential hemorrhagic shock.
G. Increase the IV fluid to maximum rate
Increasing IV fluid administration helps to restore circulating volume and stabilize the client's blood pressure. This is essential in managing hypovolemia resulting from significant postpartum hemorrhage.
H. Weigh all bloody materials
Weighing all bloody materials is a method to estimate blood loss but is not as urgent as direct interventions aimed at stopping bleeding and stabilizing the client.
I. Massage fundus until firm
Massaging the fundus helps to stimulate uterine contractions, which can help control bleeding by compressing blood vessels at the placental site. A boggy fundus indicates poor uterine tone, and firming it up is crucial to prevent further hemorrhage.

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The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

Correct Answer is "{\"xRanges\":[389.5,439.5],\"yRanges\":[222,272]}"

Explanation

Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Correct Answer is ["A","B","D","F","G","I"]

Explanation

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