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

Auscultate breath sounds.

Measure the vital signs.

Assist to a high Fowler’s position.

Initiate deep breathing exercises.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While auscultating breath sounds is an important part of assessing a client’s respiratory status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

Choice B rationale

While measuring vital signs is an important part of assessing a client’s overall status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

Choice C rationale

Assisting the client to a high Fowler’s position can help alleviate dyspnea by allowing for greater lung expansion. This should be the nurse’s first action when a client with ascites is dyspneic.

Choice D rationale

While deep breathing exercises can help improve lung function and may be beneficial for a client with ascites, they are not the first action the nurse should take when the client is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Administering morphine as prescribed would help to manage the patient’s reported pain.

Choice B rationale

Monitoring the patient’s vital signs is crucial in assessing the patient’s physiological response to the fall and ensuring stability.

Choice C rationale

Applying a cold pack to the affected area can help to reduce swelling and alleviate pain.

Choice D rationale

Arranging for an X-ray of the left shoulder would help to identify any potential fractures or other injuries resulting from the fall.

Correct Answer is ["1.32"]

Explanation

Step 1 is to convert the patient’s weight from pounds to kilograms. There are approximately 2.2046 pounds in 1 kilogram. So, the patient’s weight in kilograms is 132 lb ÷ 2.2046 = 59.87 kg.

Step 2 is to calculate the total dose of lorazepam the patient should receive. The prescribed dose is 44 mcg/kg. So, the total dose in micrograms is 44 mcg/kg × 59.87 kg = 2634.28 mcg.

Step 3 is to convert the total dose from micrograms to milligrams. There are 1000 micrograms in 1 milligram. So, the total dose in milligrams is 2634.28 mcg ÷ 1000 = 2.63428 mg.

Step 4 is to calculate the volume of lorazepam solution to administer. The concentration of the solution is 2 mg/mL. So, the volume in milliliters is 2.63428 mg ÷ 2 mg/mL = 1.31714 mL. Therefore, the nurse should administer approximately 1.32 mL of the lorazepam solution, rounding to the nearest hundredth as required.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

A patient weighing 132 lb is prescribed lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in a 2 mg/mL vial. How many mL should the nurse administer? Round off to 2 d.p. (This is a medical math nd does not require options.)

Correct Answer is ["1.32"]

Explanation

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