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 A

Explanation

Rationale

A. This is because preventing falls and injuries is crucial for individuals with osteoporosis, as their bones are more fragile and susceptible to fractures. Creating a safe environment by identifying and resolving home safety hazards can significantly reduce the risk of falls, which is essential for the well-being of someone with osteoporosis.

B. Constipation can be a concern for older adults, especially those with limited mobility. While addressing constipation is important for overall comfort and well-being, it is not directly related to osteoporosis management.

C. Understanding risk factors for osteoporosis is important for prevention and management but not of immediate concern.

D. Adequate calcium intake helps maintain bone density and reduce the risk of fractures in individuals with osteoporosis. However, this is not a priority.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse recognizes that this client is Hemorrhaging due to uterine atony.

Rationale

This client is likely experiencing hemorrhaging, as indicated by the boggy fundus (uterine atony), saturated pad and sheets with blood, and the significant estimated blood loss of 600 mL after delivery. Hemorrhaging refers to excessive bleeding, which can occur due to various reasons in the postpartum period, including uterine atony.

The boggy fundus (uterus) at 1 cm above the umbilicus suggests poor uterine tone, which is indicative of uterine atony. Uterine atony is a common cause of postpartum hemorrhage and occurs when the uterus fails to contract adequately after delivery, leading to excessive bleeding.

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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

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

Correct Answer is A

Explanation

The nurse has reviewed the client's chart. Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that this client is dropdown due to dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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.

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