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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Correct Answer is B

Explanation

Rationale

A. Starting IV infusion for antiviral drugs is premature without confirmation of COVID-19 diagnosis. Antiviral treatment for COVID-19 is typically initiated based on positive test results and clinical assessment by the healthcare provider. It is important to wait for test results before starting specific treatment protocols.

B. Given the client's symptoms and exposure history to someone with COVID-19, it is crucial to implement droplet precautions. This includes placing the client in a private room with the door closed to minimize the risk of airborne transmission. Healthcare providers should wear appropriate personal protective equipment (PPE), including masks (N95 respirator or surgical mask), gown, gloves, and eye protection, when entering the room.

C. This action is appropriate to inform family members about potential exposure to COVID-19. Symptoms can develop up to 14 days after exposure, so monitoring for symptoms is essential. However, immediate isolation and precautions for the client are more critical at this stage.

D. While it is important for the client to inform others about potential exposure, the immediate concern is implementing isolation precautions for the client and preventing further transmission within the healthcare setting.

A. Close living quarters at evacuation centers. B. Drinking water contaminated by sewage. C. Food contamination from flood waters. D. Nosocomial transmission in the medical area.

Correct Answer is B

Explanation

Rationale

A. Evacuation centers often accommodate a large number of people in close proximity. This can lead to increased transmission of infectious agents, including those causing diarrheal illnesses, through person- to-person contact or contaminated surfaces.

B. Hurricanes can cause flooding, which may overwhelm sewage systems and lead to contamination of drinking water sources. Consuming water contaminated by sewage can introduce pathogens that cause diarrheal diseases, such as bacteria like Escherichia coli or viruses like norovirus.

C. Flood waters can contaminate food supplies in various ways, such as direct contact with contaminated water, improper storage, or inadequate cooking or refrigeration. Consuming

contaminated food can result in diarrheal illnesses due to ingestion of pathogens like bacteria or parasites.

D. Nosocomial infections refer to infections acquired in healthcare settings. In a disaster medical area, improper infection control practices or overcrowding can contribute to nosocomial transmission of infectious agents, including those causing diarrheal diseases. However, this option is less likely in the context of a client seeking treatment for diarrhea immediately upon arrival at the disaster medical area.

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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

Correct Answer is B

Explanation

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

Correct Answer is B

Explanation

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

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