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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Correct choices;

Gravida 5, para 5 (G5P5)

This means the client has been pregnant 5 times and has given birth 5 times. Multiparity (having had multiple pregnancies and deliveries) is a risk factor for PPH due to uterine overdistension, which can lead to poor uterine tone and difficulty in contracting effectively after delivery.

Delivery of a 9 lb 1 oz (4.1 kg) baby

Larger babies are associated with an increased risk of PPH. The weight of the baby suggests a potentially larger placental surface area and increased uterine distension during pregnancy, which can contribute to uterine atony post-delivery.

Labor for 25 hours

Prolonged labor can lead to uterine exhaustion, where the uterus may not contract effectively after delivery, predisposing the client to PPH.

Forceps-assisted delivery

Instrumental deliveries, including forceps, can cause trauma to the birth canal, including the cervix, vagina, and perineum, increasing the risk of lacerations and bleeding.

Epidural anesthesia

Epidurals can mask the pain associated with uterine atony, which may delay the diagnosis of PPH. It's important to closely monitor uterine tone and blood loss in clients who have had epidurals.

4th degree laceration

Explanation: A 4th degree laceration involves the perineum and extends through the anal sphincter complex. Such extensive trauma increases the risk of significant bleeding postpartum.

Estimated blood loss of 600 mL

Although this is within the normal range of blood loss immediately after delivery, it still signifies that the client has experienced significant hemorrhage, putting her at higher risk for ongoing bleeding.

A. Clarify that all STIs are transmitted through sexual intercourse. B. Explain that reinfections occur from sex with untreated partners. C. Provide counseling that most contraceptives protect against infection. D. Emphasize that using safe sex practices removes the risk of STIs.

Correct Answer is B

Explanation

Rationale

A. This statement is partially true as most sexually transmitted infections (STIs), including syphilis, are primarily transmitted through sexual intercourse. However, not all STIs are exclusively transmitted through sexual contact.

B. Syphilis is caused by the bacterium Treponema pallidum and can be transmitted through direct contact with a syphilitic sore (chancre) during vaginal, anal, or oral sex. If a person has syphilis and engages in unprotected sex with a partner who is not treated, they can potentially contract or transmit the infection again, leading to reinfection.

C. While contraceptives such as condoms provide protection against unintended pregnancy and some STIs, including syphilis, they do not offer complete protection against all STIs. Condoms are effective in reducing the risk of transmission of syphilis when used consistently and correctly, but they are not 100% protective.

D. Using safe sex practices, such as consistent and correct use of condoms, reduces the risk of acquiring or transmitting STIs, including syphilis. Safe sex practices also include mutual monogamy and regular testing for STIs, especially for those who have multiple sexual partners or engage in high-risk sexual behaviors.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 ["A","B","C","D","E","F","G"]

Explanation

Correct choices;

Gravida 5, para 5 (G5P5)

Delivery of a 9 lb 1 oz (4.1 kg) baby

Labor for 25 hours

Forceps-assisted delivery

Epidural anesthesia

4th degree laceration

Estimated blood loss of 600 mL

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

Correct Answer is B

Explanation

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?