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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While placing a certified copy of the living will in the patient’s record is important, it is not the immediate next step. The living will should be acknowledged, but the healthcare provider needs to be informed immediately.
Choice B rationale
Informing the healthcare provider of the patient’s wishes is the most appropriate next step. The healthcare provider can then make decisions based on the patient’s expressed wishes.
Choice C rationale
Arranging a family meeting with the palliative care team may be beneficial, but it is not the immediate next step. The healthcare provider needs to be informed first.
Choice D rationale
Notifying the nursing staff of the patient’s do not resuscitate status is important, but it is not the immediate next step. The healthcare provider needs to be informed first.
Correct Answer is D
Explanation
Choice A rationale
Walking at least once an hour at work can be beneficial for overall health and can contribute to maintaining energy balance. However, it may not be the most effective action for maintaining energy balance for a person who already exercises 2 to 3 times per week.
Choice B rationale
Increasing exercise intensity can help burn more calories and can contribute to maintaining energy balance. However, it’s important to note that exercise alone may not be sufficient for maintaining energy balance if not combined with a balanced diet.
Choice C rationale
Avoiding foods with high carbohydrate levels is not necessarily an effective action for maintaining energy balance. Carbohydrates are a primary source of energy for the body. While it’s important to choose complex carbohydrates over simple ones, avoiding carbohydrates altogether is not recommended.
Choice D rationale
Selecting foods that are lower in caloric density is an effective action for maintaining energy balance. Foods that are lower in caloric density, such as fruits and vegetables, can provide essential nutrients without contributing excessive calories. This can help maintain energy balance and prevent weight gain.
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